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
The proof of pregnancy is in the pregnancy test.
A positive office pregnancy test would confirm the pregnancy.
Choice A, Chadwick’s sign, is not correct because it is not a definitive sign of pregnancy.
Choice B, Hegar’s sign, is also not correct because it is not a definitive sign of pregnancy.
Choice D, Fetal movement felt by the examiner, is not correct because it is not a definitive sign of pregnancy.
Correct Answer is A
Explanation
This is a variation of the side-lying position, which is recommended for pregnant women in the third trimester to improve blood flow to the uterus and the baby12.
Sleeping on the right side with a pillow under the hip can also help relieve pressure on the inferior vena cava, a large vein that carries blood from the lower body to the heart.
Sleeping on the back can cause lightheadedness and dizziness because of this pressure, as well as increase the risk of stillbirth1.
Choice B.
Without a pillow is incorrect, as this can make sleeping on the side uncomfortable and cause back pain or leg cramps.
Choice C.
with a pillow under her shoulders is incorrect, as this can elevate the upper body and worsen heartburn, a common problem in pregnancy.
Choice D.
with a pillow under both hips is incorrect, as this can make sleeping on the back more likely, which is not advised for pregnant women in the third trimester1.
Therefore, choice A is the best answer.
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