A nurse is caring for a client who had a vaginal delivery 1 day ago. The nurse determines that the client's fundus is firm, located 2 fingerbreadths above the umbilicus, and deviated to the left. Which of the following actions should the nurse take first?
Notify the provider.
Administer a prescribed analgesic
Assist the client to empty her bladder.
Monitor perineal pads for clots.
The Correct Answer is C
A) Incorrect- While notifying the provider might be necessary, addressing bladder distention takes precedence in this scenario.
B) Incorrect- Administering an analgesic might be indicated for pain relief, but addressing bladder distention is the priority.
C) Correct - Assisting the client to empty her bladder is the first action to take. A full bladder can prevent the uterus from contracting properly and can lead to excessive bleeding.
D) Incorrect- Monitoring perineal pads for clots is important but not the first action to take when bladder distention is present.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Correct - Yogurt is a good source of calcium and is a suitable recommendation for a client with low calcium levels during pregnancy.
B) Incorrect- Avocados contain healthy fats and other nutrients, but they are not a particularly high source of calcium.
C) Incorrect- Peanut butter is a source of protein and healthy fats but does not provide a significant amount of calcium.
D) Incorrect- Long-grain rice is a carbohydrate source but does not contribute much to calcium intake.
Correct Answer is C
Explanation
A) Incorrect- Administering medication into the deltoid muscle is not typically done in newborns. Phytonadione is given intramuscularly, usually in the vastus lateralis muscle, not the deltoid muscle.
B) Incorrect- Phytonadione should be given within 1 hour of birth, not 12 hours after birth. Delaying the administration increases the risk of bleeding complications.
C) Correct- The size of the needle is important for the newborn's comfort, A 25-gauge needle is the appropriate size for administering phytonadione to a newborn. A smaller needle may not deliver the medication adequately, and a larger needle may cause more tissue damage and bleeding.
D) Incorrect- The mother's Rh factor is irrelevant for the administration of phytonadione.
Rh factor affects the risk of hemolytic disease in the newborn, which is a different condition from hemorrhagic disease.
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