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. Cervical dilation.

A. Cervical dilation is a definitive sign of labor.

Cervical dilation is the opening of the cervix, and it is a key indicator of the active phase of labor. Measurement of cervical dilation is an essential component of assessing the progress of labor.

B. Brownish vaginal discharge may indicate various things, including the presence of old blood or mucus. While it could be a sign of impending labor, it is not a definitive confirmation of active labor.

C. Amniotic fluid in the vaginal vault could suggest rupture of membranes, but it alone does not confirm the active phase of labor.

D. Pain above the umbilicus is not a specific or conclusive sign of labor. Labor pain typically originates in the lower abdomen and pelvis.

A. Shortness of breath B. Breakthrough bleeding C. Vomiting D. Breast tenderness

Correct Answer is A

Explanation

The correct answer is A.

A. Shortness of breath: Shortness of breath can be a serious side effect of combined oral contraceptives (COCs) and may indicate a potential risk of a blood clot or other cardiovascular issues. It is crucial for the client to seek medical attention promptly if experiencing shortness of breath.

B. Breakthrough bleeding: Breakthrough bleeding is a common side effect of COCs, especially during the first few months of use. While it can be bothersome, it is generally not considered a serious adverse effect. However, the healthcare provider may need to adjust the dosage or type of contraceptive if breakthrough bleeding persists.

C. Vomiting: Vomiting can decrease the absorption of COCs, and if vomiting occurs within a few hours after taking the pill, a backup form of contraception may be needed. However, it is not necessarily an adverse effect that requires immediate notification unless it leads to an inability to take the medication consistently.

D. Breast tenderness: Breast tenderness is a common side effect of hormonal contraceptives and is generally not considered a serious adverse effect. Clients are often advised to monitor for changes in breast tenderness, but it does not require immediate notification.

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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?

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