A nurse is caring for a client who is postpartum and finds the fundus slightly boggy and displaced to the right. Based on these findings, which of the following actions should the nurse take?

Encourage the client to perform Kegel exercises.

Encourage the client to move to the left lateral position.

Ask the client to rate her pain.

Encourage the client to empty bladder by voiding

Answer and Explanation

The Correct Answer is D

A.   Kegel exercises are not indicated for addressing a boggy uterus; emptying the bladder is a more appropriate intervention.
B.   Moving to the left lateral position may help, but the primary concern is a full bladder contributing to uterine displacement.
C. Pain assessment is important but does not directly address the issue of a boggy uterus and displacement.
D.   Encouraging the client to empty the bladder by voiding is essential, as a full bladder can displace the uterus and contribute to uterine atony.

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Correct Answer is A

Explanation

A. The described reflex is the Moro reflex, which is a normal startle reflex in newborns.
B. The Babinski reflex involves the extension of the big toe and fanning of the other toes in response to stroking the sole of the foot.
C. The Tonic neck reflex involves turning the head to one side, with the arm on that side extending and the opposite arm flexing.
D. The Rooting reflex involves turning the head and opening the mouth in response to cheek or mouth stimulation.

A. Place 3 to 4 pillows under the client's knees when resting in bed. B. Massage the client's posterior lower legs. C. Have the client ambulate. D. Apply warm, moist heat to the client's lower extremities.

Correct Answer is C

Explanation

A. Placing pillows under the client's knees may provide comfort but does not address the prevention of thromboembolic disease.
B. Massaging the client's posterior lower legs may increase the risk of dislodging a clot in clients with a history of thromboembolic disease.
C. Having the client ambulate helps prevent venous stasis and reduces the risk of thromboembolic events.
D. Applying warm, moist heat to the client's lower extremities may provide comfort but does not address the prevention of thromboembolic disease.

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A nurse is caring for a client who is postpartum and finds the fundus slightly boggy and displaced to the right. Based on these findings, which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

While evaluating the reflexes of a newborn, the nurse notes that with a loud noise the newborn symmetrically abducts and extends his arms, his fingers fan out and form a C with the thumb and forefinger, and he has a slight tremor. The nurse would document this finding as a positive reflex.

Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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