A nurse is assessing a client who gave birth vaginally 12 hr ago and palpates her uterus to the right above the umbilicus. Which of the following Interventions should the nurse perform?

Reassess the client in 2 hr.

Administer simethicone.

Assist the client to empty her bladder.

Instruct the client to lie on her right side.

Answer and Explanation

The Correct Answer is C

Choice A Reason:

Reassess the client in 2 hours is inappropriate. While reassessment is important, addressing the cause of uterine displacement, in this case, a full bladder, should be the initial priority.

Choice B Reason:

Administering simethicone is inappropriate. Simethicone is typically used to relieve gas and bloating. It is not the primary intervention for uterine displacement related to bladder fullness.

Choice C Reason:

Assisting the client to empty her bladder is appropriate. A full bladder can displace the uterus and hinder its contraction, leading to potential issues such as uterine atony or increased postpartum bleeding. Emptying the bladder helps the uterus contract more effectively.

Choice D Reason:

Instructing the client to lie on her right side is inappropriate. Lying on the right side is often recommended to improve blood flow and oxygenation to the fetus during pregnancy but may not directly address uterine displacement caused by a full bladder. The priority is to assist the client in emptying her bladder.

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Correct Answer is D

Explanation

The correct answer is D.

A. Slowing the client's rate of breathing is not directly related to the observed uniform decelerations. The primary concern is the fetal heart rate pattern.

B. Decreasing the rate of infusion of the maintenance IV solution is not the appropriate intervention for addressing the observed fetal heart rate decelerations. The focus should be on the oxytocin infusion rate.

C. Increasing the rate of infusion of the IV oxytocin is not the appropriate action.

The patient is already experiencing frequent and strong contractions, and increasing the oxytocin rate can exacerbate the decelerations and compromise fetal well-being.

D. Discontinuing the infusion of the IV oxytocin is the correct action.

The observed uniform decelerations are likely related to oxytocin-induced hyperstimulation of the uterus. Stopping or decreasing the oxytocin infusion allows for the uterine activity to decrease, potentially improving fetal heart rate patterns.

A. Flaccid uterus B. Cervical laceration C. Excess vaginal bleeding D. Increased afterbirth cramping E. Increased maternal temperature

Correct Answer is ["A","C"]

No explanation

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A nurse is assessing a client who gave birth vaginally 12 hr ago and palpates her uterus to the right above the umbilicus. Which of the following Interventions should the nurse perform?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

A nurse is preparing to administer oxytocin to a client who is postpartum. Which of the following findings is an indication for the administration of the medication? (Select all that apply.)

Correct Answer is ["A","C"]

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