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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Notify social services. – Incorrect; while reporting may be necessary, the nurse must first gather more information.
B. Ask the parents what caused the bruises. – Correct; the nurse should first assess by asking the parents in a nonjudgmental manner to determine if the bruises are accidental or suspicious for abuse.
C. Ask the toddler what caused the bruises. – Incorrect; toddlers may have limited verbal skills, and their responses may not be reliable.
D. Notify the provider. – Incorrect; while the provider should be informed, the nurse must first assess before escalating concerns.
Correct Answer is ["B","C","E"]
Explanation
A. Hormonal imbalances – Incorrect; while maternal hormones can impact fetal growth, they are not classified as teratogens.
B. Chemicals – Correct; drugs, alcohol, and toxins (e.g., thalidomide, lead, mercury) can cause birth defects.
C. Environmental – Correct; radiation and pollutants can affect fetal development.
D. Emotional stress – Incorrect; while stress affects pregnancy outcomes, it is not classified as a teratogen.
E. Infections – Correct; infections such as rubella, toxoplasmosis, and syphilis can cause severe congenital abnormalities.
F. Physical trauma – Incorrect; trauma can harm the fetus but is not a teratogen.
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