A patient is admitted to the postpartum unit one hour after a sterile vaginal delivery of a normal neonate weighing 8 pounds 2 ounces (3.7 kg). When the client's fundus becomes boggy and displaced above the umbilicus, which action should the practical nurse (PN) take first?
Take the vital signs and open the IV infusion rate of oxytocin.
Notify the registered nurse (RN) that the client's bladder is distended.
Put the infant to breast to suckle and stimulate oxytocin secretion.
Massage the fundus and expel retained lochia and clots.
The Correct Answer is D
The practical nurse (PN) should first massage the fundus and expel retained lochia and clots to help the uterus contract and prevent postpartum hemorrhage.
Taking the vital signs and opening the IV infusion rate of oxytocin (A) may be necessary but not as urgent as massaging the fundus.
Notifying the registered nurse (RN) that the client's bladder is distended (B) is not relevant to addressing the client's boggy and displaced fundus.
Putting the infant to breast to suckle and stimulate oxytocin secretion (C) is a valid intervention, but it is not the first priority when the client's fundus becomes boggy and displaced above the umbilicus.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Vitamin tablets are unlikely to cause significant harm to the esophagus if the child vomits after ingesting them. However, toilet bowl cleaner and kerosene are corrosive substances that can cause serious damage to the esophagus and other tissues if ingested.
An unknown substance cannot be evaluated for potential harm to the esophagus.
In any case, the mother should be advised to seek immediate medical attention for her child if they have ingested any potentially harmful substance.
The PN should also follow their facility's policies and procedures for managing cases of poisoning or suspected poisoning.
Correct Answer is A
Explanation
The fact that the patient is being treated for depression and is currently taking an antidepressant medication suggests that his loss of interest in sexual intimacy may be related to his medication. Certain antidepressants can cause sexual dysfunction, including decreased libido.
Therefore, obtaining a list of medications currently being taken (A) is the most important information for the PN to obtain. While marital discord (B), frequency of sexual activity (C), and alcohol consumption (D) may be relevant information, they are not as directly related to the patient's current complaint as his medication use.
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