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?
Monitor perineal pads for clots.
Assist the client to empty her bladder.
Notify the provider.
Administer a prescribed analgesic.
The Correct Answer is B
Choice A rationale
"Monitor perineal pads for clots.”. This is incorrect because while monitoring for clots is important, it does not address the underlying issue causing the fundal deviation.
Choice B rationale
"Assist the client to empty her bladder.”. This is correct because a full bladder can cause the uterus to deviate and impede uterine involution. Emptying the bladder helps the uterus to contract properly and return to its normal position.
Choice C rationale
"Notify the provider.”. This is incorrect because the immediate action should be to address the potential cause of the deviation (a full bladder), which can be managed by the nurse.
Choice D rationale
"Administer a prescribed analgesic.”. This is incorrect because administering pain relief does not address the cause of the fundal deviation and does not alleviate the potential issue.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Increasing the frequency of feedings from the affected nipple may aggravate nipple soreness, as it doesn't allow the area to recover and heal properly between feedings.
Choice B rationale
Exposing the affected nipple to the air between feedings can help it to dry and heal, reducing soreness. Air exposure can help prevent bacterial growth and keep the nipple area healthy.
Choice C rationale
Applying vitamin E oil to the affected nipple before each feeding is not recommended as it can make the nipple slippery, affecting the baby's latch, and it might not be safe if ingested by the baby.
Choice D rationale
Washing the affected nipple with soap and water before each feeding can strip the natural oils from the skin, leading to further dryness and irritation, which can increase soreness.
Correct Answer is C
Explanation
Choice A rationale
Starting each feeding with the same breast can cause engorgement and uneven milk supply.
Choice B rationale
Introducing formula can interfere with breast milk production and breastfeeding success.
Choice C rationale
Ensuring the newborn empties the first breast allows them to receive the nutrient-rich hindmilk, which is crucial for growth.
Choice D rationale
Offering water to a newborn is unnecessary and can interfere with feeding since breast milk or formula provides sufficient hydration. .
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