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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

A) Correct- Feeling the baby's swallowing during breastfeeding indicates that the baby is effectively transferring milk from the breast. It suggests that the baby is latched on correctly and is receiving milk.
B) Incorrect- Moderate tenderness during breastfeeding is common initially, but it should not be persistent or severe.
C) Incorrect- While bowel movements are important, having at least one bowel movement every day is not necessarily an indicator of effective breastfeeding.
D) Incorrect- While wet diapers are important to ensure adequate hydration, having at least six wet diapers every day is not the primary sign of effective breastfeeding.

A. A client who has a reddened area on their right calf B. A client who reports painful uterine contractions during breastfeeding C. A client who has a urinary output of 125 mL in 4 hr D. A client who reports changing their perineal pad every 2 hr

Correct Answer is C

Explanation

A) Incorrect- A reddened area on the calf might indicate a potential blood clot (deep vein thrombosis), which is important to assess but may not be the highest priority.
B) Incorrect- Painful uterine contractions during breastfeeding can be a normal response due to oxytocin release during breastfeeding and might not require immediate reporting.
C) Correct - A urinary output of 125 mL in 4 hours is significantly low and could indicate inadequate fluid intake, potential urinary retention, or other issues that need prompt attention. It is a sign of impaired renal function. This could indicate dehydration, blood loss, infection, or kidney injury. The nurse should assess the client's fluid intake and output, vital signs, urine specific gravity, and serum electrolyte levels. The nurse should also monitor the client for signs of hypovolemia, such as tachycardia, hypotension, and decreased skin turgor.
D) Incorrect- Changing a perineal pad every 2 hours is within the normal range for postpartum bleeding and might not require immediate reporting.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a clinic is reinforcing teaching about signs of effective breastfeeding with a client who has a 5-day-old newborn. Which of the following statements by the client demonstrates an understanding of the teaching?

Correct Answer is A

Explanation

A nurse working on a postpartum unit is collecting data from four clients. Which of the following findings should the nurse report to the provider?

Correct Answer is C

Explanation

A nurse on a postpartum unit is caring for a client who delivered vaginally 24 hr ago. Which of the following should the nurse expect to find when collecting data?

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A nurse is reinforcing teaching about laboratory testing with a client who is at 6 weeks of gestation. Which of the following statements should the nurse include?

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