A nurse is caring for a client who experienced 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?
Insert a urinary catheter.
Massage the fundus.
Have the client urinate.
Administer an analgesic
The Correct Answer is C
A firm, displaced fundus to the right of midline indicates a full bladder. A distended bladder can prevent the uterus from contracting properly and can lead to uterine atony, increasing the risk of postpartum hemorrhage. Therefore, the priority action is to have the client empty her bladder.
This can often be achieved by encouraging the client to urinate or by assisting her with toileting if necessary. Palpating a fundus that is firm and displaced does not indicate the need for fundal massage, as the fundus is already firm. Inserting a urinary catheter may be necessary if the client is unable to void spontaneously, but this should be done after attempting to have the client
urinate voluntarily. Administering an analgesic is not indicated based on the information provided.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Hydrocephalus is a condition characterized by the accumulation of cerebrospinal fluid (CSF) within the ventricles of the brain, leading to increased intracranial pressure. Manifestations of hydrocephalus in a newborn may include dilated scalp veins, sunset eyes, head enlargement and sutural diastasis due to increased intracranial pressure.
Correct Answer is ["A","C","D","E"]
Explanation
A.Swaddling can provide comfort to the newborn and may help reduce symptoms of NAS such as tremors and increased muscle tone.
B. Naloxone is not routinely used in the management of neonatal abstinence syndrome (NAS). Naloxone is an opioid antagonist and is not recommended for the treatment of NAS due to the risk of precipitating acute withdrawal in the newborn, which can be life-threatening.
C. Continuing NAS scoring as prescribed is an appropriate intervention. It helps assess the severity of withdrawal symptoms and guides the management plan.
D. Breastfeeding is often encouraged in newborns with NAS as it provides comfort, nutrition, and promotes bonding between the newborn and the birthing parent.
E. Administering oral morphine is one of the pharmacological treatments commonly used for moderate to severe cases of NAS. It helps to alleviate withdrawal symptoms in the newborn and is often titrated based on the severity of symptoms and NAS scoring.
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