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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Feeling sad or having a depressed mood is a common symptom of depression. Asking the client if they often feel sad can help the practical nurse (PN) assess for depression.

While recent stresses (A), sleep changes (B), and dietary habits (C) may also be relevant to the client's situation, asking if the client often feels sad is the most important question for the PN to ask in order to further assess for depression.

A. Increased appetite. B. Sufficient urinary output. C. Fewer temper outbursts. D. Decreased muscular spasticity.

Correct Answer is A

Explanation

Baclofen is a muscle relaxant that can help relieve muscle spasms and manage conditions such as cerebral palsy¹. An assessment finding that indicates the drug is eﬀective for a child with cerebral palsy would be decreased muscular spasticity. This means that the child's muscles are less stiﬀ and rigid, which can improve their mobility and overall quality of life.

The other choices are incorrect because they are not directly related to the therapeutic eﬀects of baclofen. Baclofen is a muscle relaxant that is used to relieve muscle spasms and stiﬀness. While it may have other eﬀects on the body, its primary therapeutic eﬀect is to decrease muscular spasticity.

Increased appetite is not a known eﬀect of baclofen.
Sufficient urinary output is important for overall health, but it is not directly related to the eﬀectiveness of baclofen.
Fewer temper outbursts may be an indirect result of decreased muscular spasticity and improved mobility, but it is not a direct eﬀect of baclofen.

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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?

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Naxlex Comprehensive Predictor Exams

A client at the mental health center reports difficulty concentrating at work, feeling very tired during the day, and sleeping 4 to 5 hours at night. To further assess for depression, which question is most important for the practical nurse (PN) to ask?

Correct Answer is D

Explanation

A child with cerebral palsy (CP) is taking baclofen, a relaxant. Which assessment finding indicates to the practical nurse (PN) that the drug is eﬀective?

Correct Answer is A

Explanation

The practical nurse (PN) is caring for a newborn whose mother has poorly controlled type 1 diabetes mellitus and observes the newborn is grunting with mild sternal retractions. The PN should recognize the newborn is exhibiting signs of which condition?

Another person tells the practical nurse (PN) that her 7-year-old child frequently wets the bed at night. Which information should the PN provide?

The practical nurse (PN) is interviewing a middle-aged married male who is being treated for depression and reports an increasing lack of interest in sexual intimacy with his wife. Which information is most important for the PN to obtain?

The practical nurse (PN) caring for a 3-month-old boy one day after a pyloromyotomy notices that the infant is restless, is exhibiting facial grimaces, and is drawing his knees to his chest. What action should the PN take?

The mother of a child who is hospitalized with croup and is in a mist tent brings the child's favorite stuﬀed animal to the hospital. Which action should the practical nurse (PN) take?

A male client with paranoia has been admitted to the mental health unit, and upon arrival, he immediately goes to the corner of the room and sits quietly without communicating. In approaching the client, what intervention should the practical nurse (PN) implement first?

The practical nurse (PN) is planning care for a child with heart failure. Which intervention should the PN give the greatest priority?

A client who is multiparous at 36-weeks gestation is diagnosed with placenta previa. The practical nurse (PN) should monitor this client for which condition?