A nurse is performing a physical examination of a client who is 1 day postpartum. Which of the following findings requires immediate intervention?

Fundal height below the umbilicus

Decreased urge to void

Increased urine output

Displaced fundus from the midline

Answer and Explanation

The Correct Answer is D

A) Fundal height below the umbilicus:

In the immediate postpartum period, the fundus typically descends at a predictable rate. A fundal height below the umbilicus on the first day postpartum is expected. It is not a cause for immediate intervention unless accompanied by other signs of postpartum hemorrhage.

B) Decreased urge to void:

A decreased urge to void is common in the immediate postpartum period due to perineal swelling, episiotomy or lacerations, and the effects of regional anesthesia. However, it is not an immediate concern as long as the client is voiding adequate amounts of urine.

C) Increased urine output:

Increased urine output in the postpartum period is expected due to the diuretic effect of the body eliminating excess fluid retained during pregnancy. It is not a cause for immediate intervention as long as the client is not exhibiting signs of dehydration.

D) Displaced fundus from the midline:

A displaced fundus from the midline is concerning as it may indicate uterine atony, which is the most common cause of postpartum hemorrhage. Immediate intervention is necessary to prevent further complications such as excessive bleeding.

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Correct Answer is D

Explanation

A) Report of absent breast pain:

Absent breast pain is not a direct indicator of the effectiveness of methylergonovine, which is typically administered to promote uterine contraction and prevent postpartum hemorrhage. Breast pain is more commonly associated with lactation and breastfeeding.

B) Increase in blood pressure:

An increase in blood pressure is not an expected outcome of methylergonovine administration. In fact, methylergonovine can cause transient hypertension as a side effect due to its vasoconstrictive properties.

C) Increase in lochia:

An increase in lochia is not a direct indicator of the effectiveness of methylergonovine. While methylergonovine can promote uterine contractions, leading to expulsion of uterine contents and subsequent decrease in lochia, an increase in lochia might indicate ongoing uterine bleeding or incomplete uterine contraction.

D) Fundus firm to palpation:

The fundus being firm to palpation is the expected outcome of methylergonovine administration. Methylergonovine stimulates uterine contractions, leading to the firming of the uterine fundus. This indicates that the medication is effective in promoting uterine involution and reducing the risk of postpartum hemorrhage.

A. "There are so many variables that you'll have to ask your obstetrician." B. "The primary consideration is what type of incision was performed this time." C. "A repeat cesarean birth is safer for both you and your baby." D. "It's too soon for you to be worrying about this now."

Correct Answer is B

Explanation

A. "There are so many variables that you'll have to ask your obstetrician."

This response dismisses the client's question and fails to provide helpful information. While the client should discuss their specific situation with their obstetrician, the nurse should still offer some general guidance or information.

B. "The primary consideration is what type of incision was performed this time."

This is the correct response because it provides relevant information to the client's question. The type of incision made during the cesarean birth can influence the options for future deliveries. For example, a low transverse incision may make a vaginal birth after cesarean (VBAC) more likely, whereas a vertical incision might increase the likelihood of needing a repeat cesarean.

C. "A repeat cesarean birth is safer for both you and your baby."

This statement may not be accurate for all clients and situations. While repeat cesarean births are sometimes recommended for medical reasons, such as certain pregnancy complications or a previous cesarean with a vertical incision, it is not necessarily the safest option for all clients. This response also lacks consideration of the client's individual circumstances.

D. "It's too soon for you to be worrying about this now."

This response invalidates the client's concerns and fails to address their question. It's important to validate the client's feelings and provide them with accurate information to address their concerns.

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A nurse is performing a physical examination of a client who is 1 day postpartum. Which of the following findings requires immediate intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is postpartum and received methylergonovine. Which of the following findings indicates that the medication was effective?

Correct Answer is D

Explanation

A nurse is caring for a client who delivered a healthy term newborn via cesarean birth. The client asks the nurse, "Is there a chance that I could deliver my next baby without having a cesarean section?" Which of the following responses should the nurse provide?

Correct Answer is B

Explanation

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