Try Naxlex NCLEX-RN (Free-Trial)

A nurse is caring for a client who had a vaginal delivery 2 hr ago. Which of the following actions should the nurse anticipate in the care of this client? (Select all that apply.)

Massage a firm fundus.

Determine whether the fundus is midline.

Document fundal height.

Observe the lochia during palpation of fundus.

Administer methylergonovine maleate if uterus is boggy.

Answer and Explanation

Correct Answer : B,C,D,E

Answer: B, C, D, E

Rationale:

A) Massage a firm fundus: If the fundus is already firm, routine massage is not necessary. Instead, the nurse should monitor the fundus for firmness and position. Massaging is indicated only if the fundus is boggy or atonic to promote uterine contraction.

B) Determine whether the fundus is midline: Checking the position of the fundus is essential to assess for potential complications. A fundus that is not midline could indicate bladder distention, which can interfere with uterine contraction and lead to postpartum hemorrhage.

C) Document fundal height: Documenting the height of the fundus is important for monitoring uterine involution. The fundus should be at the level of the umbilicus 1-2 hours postpartum, and any deviation from expected findings should be noted for ongoing assessment.

D) Observe the lochia during palpation of fundus: Observing lochia during fundal assessment helps identify potential complications such as excessive bleeding or clots. It is crucial for the nurse to monitor lochia in conjunction with fundal assessment to ensure appropriate postpartum recovery.

E) Administer methylergonovine maleate if the uterus is boggy: Methylergonovine is indicated for uterine atony (a boggy uterus) to promote uterine contractions and reduce the risk of postpartum hemorrhage. If the fundus is found to be boggy during assessment, administration of this medication should be anticipated.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

A) Disseminated intravascular coagulation (DIC):
Petechiae and bleeding around the IV access site are indicative of potential DIC, a complication of abruptio placentae. DIC is a serious condition characterized by widespread activation of clotting factors, which can lead to both excessive clotting and bleeding. In abruptio placentae, the premature separation of the placenta from the uterine wall can result in significant bleeding, triggering DIC.

B) Preeclampsia:
While preeclampsia is a serious condition characterized by hypertension and proteinuria after 20 weeks of gestation, it is not directly related to the findings described in the scenario. Preeclampsia is typically associated with hypertension, proteinuria, and often edema. It is not directly associated with petechiae and bleeding around the IV access site.

C) Anaphylactoid syndrome of pregnancy:
Anaphylactoid syndrome of pregnancy (Amniotic Fluid Embolism) is a rare, but life-threatening, obstetric emergency characterized by sudden respiratory distress, circulatory collapse, and disseminated intravascular coagulation. However, petechiae and bleeding around the IV site are not typical manifestations of this condition.

D) Puerperal infection:
Puerperal infection, also known as postpartum infection, refers to infections that occur after childbirth. While it is a concern in the postpartum period, petechiae and bleeding around the IV access site are not indicative of this complication.

A. "There is an increased risk of rupture of the membranes. B. "There is an increased risk of introducing infection." C. "This could initiate preterm labor." D. "This could result in profound bleeding."

Correct Answer is D

Explanation

A) "There is an increased risk of rupture of the membranes": While there is a risk of premature rupture of membranes with placenta previa, the primary reason for avoiding internal examinations is the potential for profound bleeding. Internal examinations can dislodge the placenta, leading to significant hemorrhage, rather than directly causing rupture of the membranes.

B) "There is an increased risk of introducing infection": While infection is a concern with any internal procedure, the primary reason for avoiding internal examinations in placenta previa is the risk of provoking bleeding.

C) "This could initiate preterm labor": Internal examinations in placenta previa are not typically associated with initiating preterm labor. The primary concern is the risk of significant bleeding due to disruption of the placenta.

D) "This could result in profound bleeding": This is the correct explanation. Performing internal examinations in placenta previa increases the risk of dislodging the placenta, leading to severe bleeding. Avoiding unnecessary internal examinations helps minimize this risk and promotes the safety of both the mother and the baby.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is caring for a client who had a vaginal delivery 2 hr ago. Which of the following actions should the nurse anticipate in the care of this client? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse on the obstetric unit is caring for a client who experienced abruptio placentae. The nurse observes petechiae and bleeding around the IV access site. The nurse should recognize that this client is at risk for which of the following complications?

Correct Answer is A

Explanation

A nurse is caring for a client who is at 37 weeks of gestation and has placenta previa. The client asks the nurse why the provider does not do an internal examination. Which of the following explanations of the primary reason should the nurse provide?

Correct Answer is D

Explanation

A nurse is caring for a group of clients on an intrapartum unic. Which of the following findings should be reported to the provider immediately?

A nurse is observing the electronic fetal heart rate monitor tracing for a client who is at 40 weeks of gestation and is in labor. The nurse should suspect a problem with the umbilical cord when she observes which of the following patterns?

A nurse is assessing a client who is 4 hr postpartum following a vaginal delivery. Which of the following findings should the nurse identify as the priority?

A nurse is completing an 8-hr 1&O record for a client who consumed 4 oz juice, 6 oz tea, a 100 mL cup full of ice chips, an IV bolus of 150 mL, and 8 oz broth. The nurse should record how many mL of intake on the client's record?

A nurse is caring for a client who is at 40 weeks gestation and is in active labor. The client has 6 cm of cervical dilation and 100% cervical effacement. The nurse obtains the client's blood pressure reading as 82/52 mm Hg. Which of the following nursing interventions should the nurse perform?

A nurse is assessing a client who is pregnant for preeclampsia. Which of the following findings should indicate to the nurse that the client requires further evaluation for this disorder?

A nurse is planning care for a client who is 2 hours postpartum following a cesarean birth. The client has a History of thromboembolic disease. Which of the following nursing interventions should be included in the plan of care?

A nurse on the labor and delivery unit is caring for a client following a vaginal examination by the provider which is documented as: -1. Which of the following interpretations of this finding should the nurse make?