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 C

Explanation

A) Ask the client to rate her pain:

Assessing the client's pain is important for overall postpartum care, but it does not directly address the issue of a slightly boggy and displaced fundus. Pain assessment should be done routinely but is not the priority in this situation.

B) Encourage the client to perform Kegel exercises:

Kegel exercises are beneficial for strengthening pelvic floor muscles but do not address the issue of a boggy and displaced fundus. While Kegel exercises can promote postpartum recovery, they are not the priority intervention in this case.

C) Assist the client to the bathroom to void:

This is the correct action. A boggy and displaced fundus may indicate urinary retention, which can contribute to uterine atony. Helping the client to the bathroom to void can relieve bladder distension, allowing the uterus to contract more effectively and reducing the risk of postpartum hemorrhage.

D) Encourage the client to move to the left lateral position:

Moving to the left lateral position can help improve uterine perfusion by relieving pressure on the vena cava, but it does not directly address the issue of urinary retention or a boggy fundus. While changing positions is generally beneficial postpartum, assisting the client to void takes precedence in this situation to address the potential cause of uterine atony.

A. Educate parents on blood glucose monitoring. B. Obtain a blood sample for blood type. C. Administer thyroid hormone replacement. D. Initiate a controlled low-protein diet.

Correct Answer is D

Explanation

A) Educate parents on blood glucose monitoring:

Blood glucose monitoring is not directly related to the care of a newborn with phenylketonuria (PKU). PKU is a metabolic disorder that affects the body's ability to process phenylalanine, an amino acid found in protein. Therefore, educating parents on blood glucose monitoring is not relevant to the management of PKU.

B) Obtain a blood sample for blood type:

Obtaining a blood sample for blood type is a routine procedure performed shortly after birth to determine the newborn's blood type and Rh factor. While this is an important aspect of newborn care, it is not specific to the management of PKU.

C) Administer thyroid hormone replacement:

Administering thyroid hormone replacement is not indicated for a newborn with PKU. PKU is a metabolic disorder caused by a deficiency of the enzyme phenylalanine hydroxylase, which leads to the accumulation of phenylalanine in the body. Thyroid hormone replacement is used to treat hypothyroidism, a condition involving an underactive thyroid gland, and is not related to PKU management.

D) Initiate a controlled low-protein diet:

Initiating a controlled low-protein diet is a crucial aspect of managing PKU. Since PKU is characterized by the inability to metabolize phenylalanine properly, dietary management aims to limit phenylalanine intake by implementing a low-protein diet. This diet helps prevent the accumulation of phenylalanine in the body, reducing the risk of neurological damage and other complications associated with PKU. Therefore, including this action in the plan of care is essential for effectively managing PKU in the newborn.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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