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

The correct answer is A. Contractions lasting longer than 90 seconds.

A. Contractions lasting longer than 90 seconds can be indicative of a prolonged contraction, which may affect uteroplacental perfusion and fetal oxygenation. This is a concern and should be reported to the provider.

B. Contractions occurring every 3 to 5 minutes are within the normal frequency range during the active phase of the first stage of labor.

C. The client reporting feeling contractions in the lower back is a common description of back labor, which may occur due to the position of the baby. It is not necessarily a cause for immediate concern unless it is associated with other issues.

D. Contractions being strong in intensity is expected during the active phase of labor. Strong contractions are necessary for cervical dilation and the progression of labor.

A. Elevate the client's legs. B. Notify the provider. C. Place the client in a lateral position D. Monitor vital signs every 5 min.

Correct Answer is C

Explanation

The correct answer is C. Place the client in a lateral position.

A. Elevating the client's legs is not the priority in this situation. Placing the client in a lateral position is more appropriate to improve blood flow and prevent supine hypotension.

B. Notifying the provider is an important action but not the immediate priority. Addressing the client's position and blood pressure is crucial before contacting the provider.

C. Placing the client in a lateral position is the priority nursing action.

The low blood pressure may be due to aortocaval compression (supine hypotension) caused by the weight of the uterus on the vena cava. Turning the client onto her side alleviates this compression and helps improve blood flow.

D. Monitoring vital signs every 5 minutes is important, but the immediate action should be to address the client's position and blood pressure. Continuous monitoring and further interventions can follow.

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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 is in the active phase of the first stage of labor. When monitoring the uterine contractions, which of the following findings should the nurse report to the provider?

Correct Answer is A

Explanation

A nurse is caring for a client who is in labor and has an epidural anesthesia block. The client's blood pressure is 80/40 mm Hg and the fetal heart rate is 140/min. Which of the following is the priority nursing action?

Correct Answer is C

Explanation

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