A nurse is collecting data from a client who is 14 hr postpartum.
The nurse notes: breasts soft; fundus firm, slightly deviated to the right; moderate lochia rubra; temperature 37.7° C (100° F); pulse rate 88/min; respiratory rate 18/min.
Which of the following actions should the nurse perform?
Report the client's temperature elevation.
Encourage the client to nurse more frequently so her milk will come in.
Ask the client to empty her bladder.
Increase IV fluids.
The Correct Answer is C
A full bladder can displace the uterus and cause it to deviate to one side.
Choice A is not correct because a temperature of 37.7° C (100° F) is within the normal range for a postpartum client.
Choice B is not correct because the client’s milk production is not related to the findings noted by the nurse.
Choice D is not correct because there is no indication that the client needs an increase in IV fluids.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Pregnant vegans should ensure they are getting enough vitamin B12, which is essential for the development of the infant’s nervous system.
Vitamin B12 is found almost exclusively in animal products, so vegans should consume fortified foods such as cereals or take a supplement to ensure they are getting enough of this important nutrient.
Choice B, Milk, and cheese, is not correct because it is not vegan.
Choice C, Nuts, seeds, and chocolate, is not correct because it does not address the need for vitamin B12.
Choice D, Carrots, sweet potatoes, and mangoes, is not correct because it does not address the need for vitamin B12.
Correct Answer is C
Explanation
A child with autism spectrum disorder may have problems with social communication and interaction, including ignoring a caregiver who offers them a snack.
Choice A is incorrect because crying and stomping feet after another child takes a toy is normal behavior for a 2- or 3-year-old child.
Choice B is incorrect because repeating an action over and over is not necessarily indicative of autism spectrum disorder.
Choice D is incorrect because flipping a light switch off and on until asked to stop and join other children in playing is not necessarily indicative of autism spectrum disorder.
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