A nurse is caring for a client following a cesarean birth. The client tells the nurse that she is hungry. Which of the following actions should the nurse take first?
Offer clear liquids.
Auscultate the client's abdomen.
Check the client's chart for a diet prescription.
Give the client soda crackers.
The Correct Answer is B
Choice B reason:
Auscultating the client's abdomen is the first action the nurse should take, as it can assess the return of bowel function after surgery. The nurse should listen for bowel sounds in all four quadrants, and note their frequency and quality.
Offering clear liquids is an important action, as it can provide hydration and nutrition for the client. However, this is not the first action the nurse should take, as it may cause nausea and vomiting if the client's bowel function has not returned.
Choice C reason:
Checking the client's chart for a diet prescription is an important action, as it can ensure that the client follows the provider's orders and does not consume anything contraindicated. However, this is not the first action the nurse should take, as it does not address the client's hunger or bowel function.
Choice D reason:
Giving the client soda crackers is an important action, as it can provide a bland and easily digestible food for the client. However, this is not the first action the nurse should take, as it may be too solid for the client's stomach if her bowel function has not returned.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Fundal consistency is correct, as this finding can indicate the effectiveness of oxytocin in stimulating uterine contraction and preventing postpartum hemorrhage. Oxytocin is a uterotonic agent that can enhance or augment uterine contractility and involution. The nurse should monitor the fundal height, consistency, and position and report any signs of uterine atony or excessive bleeding.
Choice B reason: Fetal heart rate is incorrect, as this finding is not relevant for a client who has already delivered the baby. Fetal heart rate can indicate the fetal well-being and response to labor, but it is not affected by oxytocin administration after birth. The nurse should monitor the newborn's vital signs and appearance and report any signs of distress or infection.
Choice C reason: Pulse rate is incorrect, as this finding is not specific for evaluating the effectiveness of oxytocin. Pulse rate can indicate the client's hemodynamic status and response to blood loss, but it can be influenced by many other factors, such as pain, anxiety, fever, or dehydration. The nurse should monitor the client's vital signs and fluid balance and report any signs of shock or infection.
Choice D reason: Urinary output is incorrect, as this finding is not specific for evaluating the effectiveness of oxytocin. Urinary output can indicate the client's renal function and fluid balance, but it can be influenced by many other factors, such as fluid intake, bladder distension, or epidural anesthesia. The nurse should monitor the client's intake and output and report any signs of oliguria or retention.
Choice E reason: Blood pressure is incorrect, as this finding is not specific for evaluating the effectiveness of oxytocin. Blood pressure can indicate the client's hemodynamic status and response to blood loss, but it can be influenced by many other factors, such as pain, anxiety, preeclampsia, or medication. The nurse should monitor the client's vital signs and fluid balance and report any signs of hypotension or hypertension.
Correct Answer is C
Explanation
Choice A reason: Three fingerbreadths above the umbilicus is incorrect, as this position indicates a higher than expected fundal height for a client who is 12 hr postpartum. The fundus is normally at the level of the umbilicus immediately after birth and then descends about one fingerbreadth per day. A high fundal height can indicate uterine atony, retained placental fragments, or bladder distension.
Choice B reason: One fingerbreadth above the symphysis pubis is incorrect, as this position indicates a lower than expected fundal height for a client who is 12 hr postpartum. The fundus is normally at the level of the umbilicus immediately after birth and then descends about one finger-breadth per day. A low fundal height can indicate uterine inversion, which is a rare but life-threatening complication.
Choice C reason: At the level of the umbilicus is correct, as this position indicates a normal and expected fundal height for a client who is 12 hr postpartum. The fundus is normally at the level of the umbilicus immediately after birth and then descends about one finger-breadth per day. A midline and firm fundus indicates adequate uterine contraction and involution.
Choice D reason: To the right of the umbilicus is incorrect, as this position indicates a deviated fundus for a client who is 12 hr postpartum. The fundus should be midline and not displaced to either side. A deviated fundus can indicate bladder distension, which can interfere with uterine contraction and involution. The nurse should assist the client to empty their bladder and reassess the fundal position.
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