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 A

Explanation

A. Correct. In rapidly progressing labor, applying gentle perineal pressure helps control the speed of delivery and can prevent or minimize perineal tearing or lacerations. It also helps to manage the delivery of the fetal head, especially in cases where the labor is very rapid which can cause neurologic damage (increased intracranial pressure and dural/subdural tearing).

B. Cutting the umbilical cord is not the priority in this situation. The focus should be on the immediate management of the delivery process and preventing complications related to perineal tearing.

C. Preventing the perineum from tearing: While preventing the perineum from tearing is important, it is not the immediate priority in the context of rapidly progressing labor. The primary focus should be on safely delivering the baby, which involves controlling the delivery of the fetal head to prevent complications.

D. Promoting the delivery of the placenta is a consideration for the third stage of labor, which follows the delivery of the baby. It is not the priority during the active phase of delivery.

A. Cover the newborn's eyes while under the phototherapy light: It is important to protect the newborn's eyes from the bright light during phototherapy. Covering the eyes with an eye mask or using a specific eye shield helps prevent potential eye damage. B. Keep the newborn in a shirt while under the phototherapy light: The newborn should ideally be undressed and have as much skin exposed to the phototherapy light as possible. This enhances the effectiveness of the treatment by allowing more skin surface to be exposed to the light. C. Apply a light moisturizing lotion to the newborn's skin: It is generally recommended to avoid applying lotions or oils to the newborn's skin during phototherapy, as these substances can interfere with the effectiveness of the treatment. The skin should be clean and dry. D. Turn and reposition the newborn every 4 hr while undergoing phototherapy: Turning and repositioning the newborn is important for general care, but the frequency may be more frequent than every 4 hours, especially when undergoing phototherapy. The goal is to ensure even exposure of the skin to the light.

Correct Answer is A

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

A nurse is caring for a client who presents to a labor and delivery unit experiencing rapidly progressing labor. Which of the following is the priority action for the nurse to take?

Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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