A nurse is assisting in the care of a client who had a vaginal birth 2 hours ago. Which of the following actions should the nurse take? (Select all that apply.)
Document fundal height
Observe the lochia during palpation of fundus
Massage a firm fundus
Determine whether the fundus is midline
Administer terbutaline if the fundus is boggy
Correct Answer : A,B,D
Choice A:
Document fundal height. This is a correct action because the nurse should monitor the involution of the uterus by measuring the fundal height and comparing it to the expected level. The fundus should descend about one fingerbreadth (1 cm) per day after delivery and be at the level of the umbilicus immediately after birth.
Choice B:
Observe the lochia during palpation of the fundus. This is a correct action because the nurse should assess the amount, color, and consistency of the lochia (vaginal discharge) during the fundal massage. The lochia should change from rubra (red) to serosa (pink) to alba (white) over time and not increase in amount or revert to a previous stage.
Choice C:
Massage a firm fundus. This is an incorrect action because a firm fundus indicates adequate uterine contraction and involution. Massaging a firm fundus can cause discomfort and bleeding for the client. The nurse should only massage a boggy (soft) fundus to stimulate contraction and prevent hemorrhage.
Choice D:
Determine whether the fundus is midline. This is a correct action because the nurse should check if the fundus is deviated to either side, which may indicate a full bladder. A full bladder can interfere with uterine contraction and cause bleeding or infection. The nurse should assist the client to void if the fundus is not midline.
Choice E:
Administer terbutaline if the fundus is boggy. This is an incorrect action because terbutaline is a tocolytic drug that relaxes the uterine muscle and inhibits contractions. It is used to stop preterm labor, not to treat postpartum hemorrhage. The nurse should administer oxytocin or other uterotonic drugs if the fundus is boggy and does not respond to massage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
Diminished deep-tendon reflexes are a sign of magnesium toxicity, not safety. Magnesium sulfate is a central nervous system depressant that can cause muscle weakness, respiratory depression, and cardiac arrest if given in excess. The nurse should monitor the client's deep-tendon reflexes and stop the infusion if they are absent or reduced.
Choice B reason:
A respiratory rate of 16/min is a normal finding and indicates that the client is not experiencing respiratory depression from magnesium sulfate. The nurse should monitor the client's respiratory rate and stop the infusion if it falls below 12/min.
Choice C reason:
A heart rate of 60/min is a normal finding and indicates that the client is not experiencing bradycardia from magnesium sulfate. The nurse should monitor the client's heart rate and stop the infusion if it falls below 50/min.
Choice D reason:
Urine output of 50 mL in 4 hr is a sign of oliguria, not safety. Magnesium sulfate can cause renal impairment and fluid retention if given in excess. The nurse should monitor the client's urine output and stop the infusion if it falls below 30 mL/hr.
Correct Answer is ["B","C","D","E"]
Explanation
Choice A reason:
Hypertonic is not a type of cerebral palsy, but a term that describes increased muscle tone or stiffness. Hypertonicity can be a symptom of spastic cerebral palsy, which is the most common type of the disorder.
Choice B reason:
Spastic is a type of cerebral palsy that affects about 80% of people with the disorder. People with spastic cerebral palsy have stiff and jerky movements due to increased muscle tone.
Spastic cerebral palsy can be further classified by the body parts affected, such as spastic hemiplegia, spastic diplegia or spastic quadriplegia.
Choice C reason:
Hypotonic is a type of cerebral palsy that affects muscle tone and posture. People with hypotonic cerebral palsy have low muscle tone or floppiness, which makes them appear limp and relaxed. Hypotonic cerebral palsy can affect the whole body or specific parts, such as the trunk, limbs or face.
Choice D reason:
Ataxic is a type of cerebral palsy that affects balance and coordination. People with ataxic cerebral palsy have difficulty with precise movements, such as writing, buttoning a shirt or reaching for a book. They may also walk in an unsteady manner or have problems with depth perception.
Choice E reason:
Mixed is a type of cerebral palsy that includes symptoms of more than one type of the disorder. For example, a person with mixed cerebral palsy may have both spastic and dyskinetic movements, or both ataxic and hypotonic features. Mixed cerebral palsy is usually caused by damage to multiple areas of the brain.
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