A nurse is assisting in the care of a client who is 4 hr postpartum. Which of the following interventions should the nurse perform after finding that the client's uterus is not firm? (Select all that apply.)

Ask the client to empty their bladder

Perform fundal massage

Nothing, this is an expected finding

Ambulate the client in the hallway

Give pain medications

Answer and Explanation

Correct Answer : A,B

A. Ask the client to empty their bladder – Correct; a full bladder can displace the uterus and prevent it from contracting effectively.
B. Perform fundal massage – Correct; fundal massage helps stimulate uterine contractions and reduce postpartum bleeding.
C. Nothing, this is an expected finding – Incorrect; a boggy uterus is not expected and requires intervention to prevent hemorrhage.
D. Ambulate the client in the hallway – Incorrect; while ambulation is beneficial postpartum, it is not the immediate intervention for a non-firm uterus.
E. Give pain medications – Incorrect; pain medications do not directly address uterine atony or bleeding.

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Correct Answer is C

Explanation

A. Lightening – Correct; "lightening" occurs when the fetal head descends into the pelvis, reducing pressure on the diaphragm, making it easier to breathe.

B. Decreasing chest diameter – Incorrect; the chest diameter does not decrease; instead, the diaphragm moves upward due to uterine growth.

C. Decreased carbon dioxide production – Incorrect; CO₂ production remains stable during pregnancy.

D. Hyperventilation – Incorrect; while pregnancy increases respiratory effort, the client is experiencing relief, not hyperventilation.

A. Fraternal B. Dizygotic C. Trizygotic D. Monozygotic

Correct Answer is D

Explanation

A. Fraternal – Incorrect; fraternal twins develop from two separate eggs and sperm and do not share identical genetic material.
B. Dizygotic – Incorrect; dizygotic twins are fraternal twins with different genetic makeup.
C. Trizygotic – Incorrect; trizygotic refers to triplets, not twins.
D. Monozygotic – Correct; monozygotic twins result from one fertilized egg that splits, leading to identical genetic material.

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A nurse is assisting in the care of a client who is 4 hr postpartum. Which of the following interventions should the nurse perform after finding that the client's uterus is not firm? (Select all that apply.)

Nursing Test Bank

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