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 B

Explanation

A. Second stage, active phase – Incorrect; the second stage begins at 10 cm dilation, not 7 cm.
B. First stage, active phase – Correct; the active phase of the first stage occurs from 6-10 cm dilation and includes increased discomfort and pressure.
C. First stage, latent phase – Incorrect; the latent phase occurs 0-5 cm dilation, before active labor.
D. Second stage, latent phase – Incorrect; the second stage starts at 10 cm when pushing begins.

A. Picture book about hospitals B. Toy hammer and pounding board C. Stuffed animal D. Set of building blocks

Correct Answer is C

Explanation

A. Picture book about hospitals – Incorrect; a picture book may help older children but is not as effective for a 2-year-old experiencing separation anxiety.

B. Toy hammer and pounding board – These toys can be good for physical activity, but they might not be calming during a stressful tantrum.

C. Stuffed animal – Correct; comfort objects help reduce anxiety and provide security in an unfamiliar environment.

D. Set of building blocks – Incorrect; blocks help with fine motor development but do not directly address stress relief as well as other options.

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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

Naxlex Comprehensive Predictor Exams

In which stage and phase of labor is the client who is at 7 cm of cervical dilation and 100% effacement, with the fetus at 1 station and intact amniotic membranes, and reporting the urge to push?

Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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