A nurse is collecting data from a client who gave birth 12 hours ago. The nurse notes the fundus is deviated to the right, boggy, and 2 cm above the umbilicus. Which of the following actions should the nurse take first?
Administer methylergometrine to the client.
Assist the client to void.
Insert an indwelling urinary catheter.
Obtain a stat hemoglobin level.
The Correct Answer is B
Choice A reason:
Administering methylergometrine to the client is not the first action the nurse should take. Methylergometrine is a medication that stimulates uterine contractions and can help reduce postpartum bleeding. However, it can also cause hypertension and should be used with caution in clients with high blood pressure. Furthermore, the nurse should first identify and address the cause of the boggy and deviated fundus before giving any medication.
Choice B reason:
Assisting the client to void is the first action the nurse should take. A full bladder can displace the uterus and prevent it from contracting properly, leading to uterine atony and bleeding.
The nurse should help the client empty her bladder by encouraging her to use the bathroom, providing privacy, running water, or using a bedpan. This can help the uterus return to its normal position and tone.
Choice C reason:
Inserting an indwelling urinary catheter is not the first action the nurse should take. A urinary catheter can be used to drain the bladder if the client is unable to void or has a large amount of residual urine. However, it can also increase the risk of infection and trauma to the urethra
and bladder. The nurse should first try noninvasive methods to help the client void, such as those mentioned in choice B.
Choice D reason:
Obtaining a stat hemoglobin level is not the first action the nurse should take. A hemoglobin level can indicate the extent of blood loss and the need for transfusion or other interventions. However, it is not a priority over restoring uterine tone and preventing further bleeding. The nurse should first assist the client to void and then massage the fundus if it remains boggy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
Contractions every 3 to 4 min are not a definitive sign of labor, as they can also occur in false labor or Braxton Hicks contractions. These are irregular and do not cause cervical changes.
Choice B reason:
Cervical dilation is the most reliable indicator of true labor, as it shows that the uterus is contracting effectively and preparing for delivery. Cervical dilation is measured in centimeters from 0 to 10, with 10 being fully dilated.
Choice C reason:
Pain just above the navel is not a sign of labor, but rather a possible sign of an abdominal problem such as appendicitis or gallbladder disease. Labor pain usually starts in the lower back and radiates to the abdomen and thighs.
Choice D reason:
Amniotic fluid in the vaginal vault is not a conclusive sign of labor, as it can also result from a premature rupture of membranes (PROM) or a high leak of amniotic fluid. PROM occurs when the amniotic sac breaks before the onset of labor, which can increase the risk of infection and complications for the mother and the baby.
Correct Answer is A
Explanation
Choice A reason:
Placental insufficiency is a condition in which the placenta does not deliver enough oxygen and nutrients to the developing baby, resulting in restricted growth and development. This is one of the most common causes of SGA babies.
Choice B reason:
Primipara means a woman who is pregnant for the first time or who has given birth to one child. Primipara is not a cause of SGA, although some studies have suggested that first-time mothers may have a slightly higher risk of having a low-birth-weight baby than multiparous women.
Choice C reason:
Maternal obesity is a condition in which the mother has a body mass index (BMI) of 30 or higher before or during pregnancy. Maternal obesity is not a cause of SGA, but rather a risk factor for having a large-for-gestational-age (LGA) baby, which can lead to complications such as macrosomia, shoulder dystocia, and birth trauma.
Choice D reason:
Perinatal asphyxia is a condition in which the baby does not receive enough oxygen before, during, or after birth, causing hypoxia and acidosis. Perinatal asphyxia is not a cause of SGA, but rather a possible complication of SGA, especially if the placental insufficiency is severe or prolonged. Perinatal asphyxia can damage the brain and other organs of the baby and lead to long-term neurological impairments.
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