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
Carrots, while nutritious and rich in vitamins, are not a significant source of iron. They provide fiber and beta-carotene but do not meet the increased iron needs during pregnancy.
Choice B rationale
Chicken breast is an excellent source of heme iron, which is more easily absorbed by the body compared to non-heme iron found in plant-based foods. Consuming chicken breast helps in meeting the increased iron requirements during pregnancy.
Choice C rationale
Apples are healthy and provide essential nutrients and fiber but are not a significant source of iron. They contribute to overall well-being but do not address the specific need for increased iron intake.
Choice D rationale
Feta cheese is a good source of calcium and protein but not iron. While it contributes to nutritional intake during pregnancy, it does not help in meeting the increased iron needs.
Correct Answer is []
Explanation
Based on the information provided, the client is most likely experiencing C. Hyperemesis gravidarum. This condition is characterized by severe nausea and vomiting, which can lead to dehydration and electrolyte imbalances.
Actions to Take:
- B. Inspect mucous membranes - To assess for signs of dehydration, such as dry mucous membranes.
- D. Administer antiemetic medications - To help control nausea and vomiting.
Parameters to Monitor:
- A. Electrolyte values - To monitor for any imbalances, especially given the low potassium level.
- B. Urine ketones - To check for ketonuria, which can indicate severe vomiting and dehydration.
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