A nurse is caring for a client who is 14 hours postpartum.
The nurse notes that the client’s breasts are soft, the fundus is firm and slightly deviated to the right, and the client’s
pulse rate is 88/min with a respiratory rate of 18/min.
Which of the following actions should the nurse take?
Ask the client to empty her bladder
Repeat the client’s temperature evaluation
Encourage the client to nurse more frequently
Check for signs of a urinary tract infection
The Correct Answer is A
Choice A rationale:
A full bladder can displace the uterus to the right and interfere with its ability to contract properly. This can lead to
postpartum hemorrhage, a serious complication that can occur after childbirth.
Emptying the bladder helps to reposition the uterus in the midline and allows it to contract more effectively. This helps to
prevent postpartum hemorrhage and promotes uterine involution, the process by which the uterus returns to its pre-
pregnancy size.
In this case, the client's fundus is firm, which indicates that it is contracting well. However, it is slightly deviated to the right,
which suggests that the bladder may be full.
Asking the client to empty her bladder is a simple and effective way to address this potential problem.
Choice B rationale:
Repeating the client's temperature evaluation is not a priority action in this case. The client's vital signs are within normal
limits, and there is no indication of infection.
A temperature elevation could be a sign of infection, but it is not the most likely cause of the uterine deviation in this case.
Choice C rationale:
Encouraging the client to nurse more frequently may be helpful in stimulating milk production and uterine contractions.
However, it is not the most immediate priority in this case.
The client's breasts are soft, which suggests that she is not yet producing a significant amount of milk.
The priority is to address the potential problem of a full bladder, which could interfere with uterine involution.
Choice D rationale:
Checking for signs of a urinary tract infection is not a priority action in this case. The client does not have any urinary
symptoms, such as dysuria or frequency.
A urinary tract infection could cause a uterine deviation, but it is not the most likely cause in this case.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
Choice A rationale:
The client is in the second stage of labor because she is actively pushing and the fetal head is at the vaginal station.
The second stage of labor is defined as the time from full cervical dilation to the birth of the baby. It is characterized by strong,
regular contractions and the urge to push.
Decelerations in the fetal heart rate can occur during the second stage of labor due to a variety of factors, including head
compression, cord compression, and uteroplacental insufficiency.
Choice B rationale:
The nurse should apply an oxygen mask to the client to increase the oxygen supply to the fetus.
This can help to improve fetal heart rate and prevent further decelerations.
Oxygen is a vital nutrient for the fetus, and it is essential for maintaining a normal fetal heart rate.
When the fetal heart rate decelerates, it is a sign that the fetus is not getting enough oxygen.
Applying an oxygen mask to the mother can help to increase the amount of oxygen that is available to the fetus.
Choice D rationale:
The nurse should monitor the client's vital signs and fetal heart rate to assess the client's progress and the well-being of the
fetus.
Vital signs, such as blood pressure, pulse, and respiration rate, can provide important information about the mother's health
and how she is coping with labor.
The fetal heart rate is a direct measure of the fetus's well-being.
By monitoring these parameters, the nurse can identify any potential problems and intervene as needed.
Additional notes:
The nurse should also encourage the client to change positions, as this can help to relieve cord compression.
The nurse should also prepare for the possibility of a rapid delivery, as decelerations in the fetal heart rate can sometimes be a
sign of fetal distress.
Correct Answer is A
Explanation
Choice A rationale:
Contraction duration: Contractions that last longer than 75 seconds are considered abnormal and should be reported to the
provider. This is because prolonged contractions can decrease oxygen supply to the fetus, leading to fetal distress.
Risk of uterine rupture: Excessively long contractions can also increase the risk of uterine rupture, a serious complication that
can endanger both the mother and the fetus.
Signs of fetal distress: The nurse should closely monitor the fetal heart rate for any signs of distress, such as late decelerations,
decreased variability, or bradycardia.
Need for intervention: If the contractions remain prolonged or if fetal distress is detected, the provider may need to intervene
to ensure the safety of both the mother and the fetus. This could involve measures such as administering medications to stop
or slow down labor, or performing a cesarean delivery.
Choice B rationale:
Contraction resting period: A contraction resting period of 35 seconds is within the normal range. Ideally, the resting period
between contractions should be at least 60 seconds, but it can vary. However, a resting period shorter than 30 seconds could
be a sign of tachysystole (excessively frequent contractions), which may also require intervention.
Choice C rationale:
Maternal heart rate: A maternal heart rate of 100 beats per minute is considered normal during labor. Heart rate can increase
with exertion, pain, and anxiety, which are common during labor. However, it's important to monitor for significant
tachycardia (heart rate over 120 beats per minute), which could indicate underlying issues such as dehydration or infection.
Choice D rationale:
Contraction frequency: One contraction in a 10-minute period is not indicative of active labor. Labor is typically defined as
having regular contractions that are 5 minutes apart or less, lasting for 45-60 seconds each, and causing progressive cervical
change. In early labor, contractions may be more sporadic and less intense.
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