A nurse is caring for a client who experience a vaginal birth 3 hr ago. Upon palpation, the fundus is displaced to the right of midline, is firm, and is two fingerbreadths above the umbilicus. Which of the following actions should the nurse complete at this time?
Massage the fundus.
Insert a urinary catheter.
Have the client urinate.
Administer an analgesic
The Correct Answer is C
A. Massage the fundus: Fundal massage is indicated when the uterus is boggy to promote uterine contraction and prevent postpartum hemorrhage. In this case, the fundus is already firm, indicating adequate uterine tone. Massaging a firm uterus is unnecessary and does not address the cause of displacement.
B. Insert a urinary catheter: Bladder distention can displace the uterus to the right and above the expected level. Although catheterization may be needed if the client cannot void, the initial intervention should be less invasive. Encouraging spontaneous voiding is preferred before proceeding to catheter insertion.
C. Have the client urinate: A firm uterus that is displaced from midline and elevated suggests bladder distention. Having the client urinate helps relieve bladder fullness, allowing the uterus to return to the midline and descend appropriately. This intervention directly addresses the likely cause of the abnormal fundal position.
D. Administer an analgesic: Analgesics may help manage postpartum discomfort but do not correct uterine displacement or bladder distention. Pain control does not influence uterine position or fundal height in this situation. Addressing bladder emptying is the priority intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Rapid, shallow breathing: Changes in respiratory pattern can occur with anxiety, pain, or respiratory compromise and are not specific indicators of increased intracranial pressure. ICP-related respiratory changes typically involve irregular or decreased respirations as brainstem compression develops. This finding alone does not reliably signal rising ICP.
B. Irregular, rapid heart rate: An irregular or rapid heart rate may be associated with pain, fever, hypoxia, or stress. With increased intracranial pressure, the classic cardiovascular response is bradycardia rather than tachycardia.
C. Increased diastolic pressure with narrowing pulse pressure: Increased intracranial pressure is associated with widening pulse pressure due to rising systolic pressure and falling diastolic pressure. Narrowing pulse pressure suggests hypovolemia or shock rather than ICP elevation. This finding does not align with Cushing’s triad.
D. Confusion and altered mental status: Changes in level of consciousness are the earliest and most sensitive indicators of increased intracranial pressure in children. Confusion, restlessness, and altered responsiveness reflect impaired cerebral perfusion. Prompt recognition of these neurologic changes is critical to prevent further brain injury.
Correct Answer is A
Explanation
A. Assess deep tendon reflexes: Magnesium sulfate depresses neuromuscular excitability, which helps prevent seizures. Monitoring deep tendon reflexes, particularly the patellar reflex, allows the nurse to evaluate therapeutic levels and detect early signs of magnesium toxicity, indicating whether the drug is effectively controlling neuromuscular activity.
B. Assess for edema: Edema is a common symptom of preeclampsia but does not directly reflect the effectiveness of magnesium sulfate in preventing seizures. While important for overall assessment, it is not a reliable indicator of seizure control.
C. Assess the client’s mucous membranes: Monitoring mucous membranes helps evaluate hydration status but does not provide information regarding the effectiveness of magnesium sulfate therapy in seizure prevention.
D. Assess the client’s skin turgor: Skin turgor is a measure of fluid status and hydration but does not indicate the therapeutic effect of magnesium sulfate on seizure control in clients with preeclampsia.
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