A nurse is caring for a patient who experienced a vaginal birth 3 hours ago.
Upon palpation, the fundus is displaced to the right of the midline, is firm, and is two fingerbreadths above the umbilicus.
What actions should the nurse complete at this time?
Insert a urinary catheter.
Massage the fundus.
Have the patient urinate.
Administer an analgesic.
The Correct Answer is C
Choice A rationale
Inserting a urinary catheter is not typically the first action when the fundus is displaced. It is more commonly done when the bladder is distended and the patient is unable to urinate.
Choice B rationale
Massaging the fundus is usually done when the uterus is soft or boggy to help it contract and prevent postpartum hemorrhage. However, in this case, the fundus is firm, indicating that the uterus is well contracted.
Choice C rationale
Having the patient urinate is the appropriate action when the fundus is displaced to the right of the midline. This displacement often indicates a full bladder, which can push the uterus to the side. After the patient urinates, the uterus often returns to the midline position.
Choice D rationale
Administering an analgesic is not the first action when the fundus is displaced. Pain medication is typically given for postpartum discomfort or afterbirth pains, not for a displaced fundus.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Betamethasone does not increase the fetal heart rate. It is a corticosteroid given to pregnant women who are at risk of preterm delivery to enhance fetal lung maturity and prevent respiratory distress syndrome.
Choice B rationale
Betamethasone is not used to stop preterm labor contractions. Other medications, such as tocolytics, are used for this purpose.
Choice C rationale
This is the correct answer. Betamethasone is given to promote fetal lung maturity. It is usually given in two doses, 24 hours apart, and takes effect within 24 hours of administration.
Choice D rationale
Betamethasone does not halt cervical dilation. It is given to enhance fetal lung maturity, not to stop labor.
Correct Answer is A
Explanation
Choice A rationale
An ectopic pregnancy, where the fertilized egg attaches outside the uterus, often presents with unilateral, cramp-like abdominal pain. This is because as the fertilized egg grows in an area where it cannot survive, it can cause irritation and bleeding, leading to pain. This pain is often one-sided or unilateral and can vary from mild to severe. It’s one of the key symptoms that can suggest an ectopic pregnancy in the early weeks of gestation.
Choice B rationale
Severe nausea and vomiting are not typically the primary symptoms associated with an ectopic pregnancy. While nausea can be a symptom of early pregnancy, severe nausea and vomiting alone without other symptoms would not necessarily indicate an ectopic pregnancy.
Choice C rationale
Uterine enlargement greater than expected for gestational age is not a symptom of an ectopic pregnancy. In fact, because the pregnancy is not in the uterus, the size of the uterus may not correlate with the expected size at the given gestational age.
Choice D rationale
While vaginal bleeding can occur in an ectopic pregnancy, it is not typically a large amount. The bleeding is often lighter than normal menstrual bleeding and may be associated with a change in color of the vaginal discharge.
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