A nurse is monitoring a client following a cesarean birth 6 hr ago who received an IV bolus oxytocin immediately after birth but continues to have a boggy fundus. Which of the following should the nurse identify as the priority intervention?
Assess for bladder distention
Apply supplemental oxygen via nonrebreather mask.
Administer intramuscular methylergonovine.
Analyze coagulation studies.
The Correct Answer is A
A. Assess for bladder distention: A full bladder can prevent the uterus from contracting effectively, leading to a boggy fundus and increased risk of postpartum hemorrhage. Assessing and addressing bladder distention is the priority because it directly impacts uterine tone and hemorrhage prevention.
B. Apply supplemental oxygen via nonrebreather mask: Oxygen may be necessary if the client shows signs of hypoxia or shock, but it does not address the primary cause of a boggy uterus. The priority is to correct the underlying issue affecting uterine contraction.
C. Administer intramuscular methylergonovine: Methylergonovine is used to promote uterine contraction, but pharmacologic intervention should follow initial assessment to identify reversible causes such as bladder distention. Administering medication without assessment could overlook a correctable mechanical issue.
D. Analyze coagulation studies: Coagulation studies are important if bleeding persists or coagulopathy is suspected, but they are not the immediate priority in a client with a boggy fundus shortly after birth. Immediate interventions to promote uterine contraction take precedence.
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Related Questions
Correct Answer is B
Explanation
A. Teach the client to use compression stockings: Compression stockings are primarily used to prevent venous thromboembolism and edema, not to relieve osteoarthritis pain. They do not address joint stiffness or muscle discomfort associated with osteoarthritis.
B. Place a moist heating pad over the affected area: Heat therapy helps relax muscles, increase blood flow, and reduce joint stiffness, providing effective non-pharmacological pain relief for osteoarthritis. Moist heat is often preferred because it penetrates deeper into the tissues compared to dry heat.
C. Avoid platelet-rich plasma therapy: Platelet-rich plasma therapy is an invasive treatment option and is not considered a routine non-pharmacological intervention for osteoarthritis pain. Avoidance of this therapy is not a direct pain-relief strategy.
D. Encourage the client to use crutches to ambulate: Crutches are generally not indicated for osteoarthritis pain unless severe weight-bearing restrictions are needed. They do not actively relieve joint pain and may increase fatigue or strain in other areas.
Correct Answer is D
Explanation
A. Severe abdominal pain: Severe abdominal pain is more commonly associated with placental abruption, not placenta previa. In placenta previa, the placenta covers the cervical opening, which typically causes painless bleeding rather than significant abdominal discomfort.
B. Delayed menses: Delayed menses is not related to placenta previa. This condition occurs during pregnancy, after menses have already ceased, and does not influence menstrual timing.
C. Nausea: Nausea is a common symptom in early pregnancy due to hormonal changes but is not a characteristic finding of placenta previa. It does not help in diagnosing or identifying this placental complication.
D. Spotting: Spotting or painless vaginal bleeding, especially in the second or third trimester, is a hallmark sign of placenta previa. The bleeding occurs because the placenta partially or completely covers the cervical os, and it often requires careful monitoring and management to prevent maternal and fetal complications.
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