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
Elevating the head of the bed can help to reduce pressure on the cervical spine and promote comfort for the client.
Choice A is not correct because a pelvic girdle is not used with halo traction.
Choice B is not correct because placing the client in a supine position can increase pressure on the cervical spine.
Choice D is not correct because elevating the foot of the bed would not provide any benefit for a client in halo traction.
Correct Answer is B
Explanation
The nurse should instruct the parents to bring the infant’s favorite blanket to the hospital.
This can provide comfort and a sense of familiarity for the infant during their hospital stay.
Choice A is incorrect because reading a story about hospitalization to an 8- month-old infant may not be developmentally appropriate.
Choice C is incorrect because parents are usually allowed to stay with their infant during hospitalization.
Choice D is incorrect because manipulating the infant’s bedtime based on the hospital’s visiting hours is not necessary.
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