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 C
Explanation
Symmetry of the hips is a normal finding and is not a sign of developmental hip dysplasia.
Choice A is not correct because limited abduction of the affected hip is a sign of developmental hip dysplasia.
Choice B is not correct because it includes all the other choices.
Choice D is not correct because shortening of the femur can be a sign of developmental hip dysplasia.
Correct Answer is D
Explanation
Involution is the process by which the uterus returns to its nonpregnant size and function after delivery.
Choice A is not correct because evolution refers to the gradual development of something.
Choice B is not correct because decrement refers to a reduction in size or value.
Choice C is not correct because progression refers to the process of developing or moving gradually toward a more advanced state.
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