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
Explanation
Choice A rationale:
Normal progression of labor: After the fetal head is delivered, the shoulders typically follow immediately. The nurse should be prepared to assist with the delivery of the shoulders to ensure a safe and smooth birth process.
Significance of retraction: Retraction of the fetal head against the maternal perineum, also known as the "turtle sign," is a classic indicator of shoulder dystocia. While this sign does not guarantee shoulder dystocia, it warrants immediate preparation for potential management.
Anticipating shoulder dystocia: By anticipating the possibility of shoulder dystocia, the nurse can take proactive measures to minimize risks and facilitate delivery. These measures may include:
Positioning the mother appropriately (e.g., McRoberts maneuver)
- Applying suprapubic pressure
- Performing internal maneuvers (e.g., Rubin's maneuver)
- Breaking the clavicle (in extreme cases)
Choice B rationale:
Ineffective in shoulder dystocia: Encouraging the mother to push during the next contraction is not an effective intervention
for shoulder dystocia. In fact, excessive pushing can worsen the impaction of the shoulders and potentially lead to
complications such as fetal hypoxia, brachial plexus injury, or maternal perineal trauma.
Choice C rationale:
Necessary in confirmed dystocia: Calling for additional medical support is crucial if shoulder dystocia is confirmed. However,
immediate preparation for shoulder delivery should commence without delay, as prompt action is essential to prevent adverse
outcomes.
Choice D rationale:
Secondary concern: While pain relief medication may be administered for maternal comfort, it is not a priority intervention in
this situation. The primary focus should be on managing the potential shoulder dystocia and ensuring the safe delivery of the
baby.
Correct Answer is D
Explanation
Choice A rationale:
Rh positive individuals already have the Rh factor on their red blood cells, so they do not need Rho(D) immune globulin to
prevent sensitization.
The newborn being Rh positive does not pose a risk to an Rh positive mother, as their blood types are compatible.
Choice B rationale:
Rh positive individuals cannot develop antibodies against the Rh factor, as it is already present on their own red blood cells.
The newborn's Rh negative status does not create a risk of sensitization for the mother, as there is no Rh factor to trigger an
immune response.
Choice C rationale:
If both the mother and the newborn are Rh negative, there is no risk of Rh incompatibility.
This is because neither individual has the Rh factor on their red blood cells, so there is no potential for sensitization.
Choice D rationale:
When an Rh negative mother carries an Rh positive fetus, there is a risk of Rh sensitization during pregnancy and delivery.
This occurs when fetal blood cells cross the placenta and enter the mother's bloodstream, exposing her immune system to the
Rh factor.
If the mother's immune system recognizes the Rh factor as foreign, it can produce antibodies against it.
These antibodies can cross the placenta in subsequent pregnancies and attack the red blood cells of Rh positive fetuses,
leading to hemolytic disease of the newborn (HDN).
Rho(D) immune globulin is a medication that can prevent Rh sensitization by binding to Rh positive fetal blood cells that have
entered the mother's bloodstream.
This prevents the mother's immune system from recognizing the Rh factor and producing antibodies.
Rho(D) immune globulin is typically given to Rh negative mothers within 72 hours of delivery of an Rh positive newborn, as well as after other events that could lead to Rh sensitization, such as miscarriage, abortion, or ectopic pregnancy.
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