A postpartum client's fundus is firm, 3 cm above the umbilicus, and displaced to the right. Which of the following interventions should the nurse take?

Assist the client to void then reassess the fundus.

Document the findings as within normal limits.

Gently massage the client's fundus.

Encourage the client to ambulate.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

Assisting the client to void is a priority intervention in this situation. A full bladder can displace the uterus and prevent it from contracting effectively, leading to a boggy and high- positioned fundus. After the client empties her bladder, the nurse should reassess the fundus to ensure it has descended to its appropriate location, which is usually at or just below the level of the umbilicus.

Choice B rationale:

Documenting the findings as within normal limits is incorrect because a firm, displaced fundus that is 3 cm above the umbilicus is not considered normal. This finding indicates that the uterus is not contracting adequately, and the nurse should take appropriate actions to address the issue.

Choice C rationale:

Gently massaging the client's fundus is not the correct intervention in this case. Massaging a firm fundus could cause uterine irritation and should be avoided. Instead, the nurse should encourage the client to empty her bladder, which often helps the uterus contract and descend to its proper position.

Choice D rationale:

Encouraging the client to ambulate may be helpful in some cases to promote uterine contractions and involution. However, in this situation, the priority is to address the full bladder, as it is a common cause of a displaced and high fundus shortly after delivery.

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Correct Answer is ["B","C"]

Explanation

Choice A rationale:

Edema is not an expected finding of uncomplicated gestational hypertension. While some degree of edema can be common during pregnancy, it is not specifically related to gestational hypertension.

Choice B rationale:

A blood pressure reading of 155/92 is an expected finding in a client with uncomplicated gestational hypertension. Gestational hypertension is defined as systolic blood pressure ≥140 mmHg or diastolic blood pressure ≥90 mmHg after 20 weeks of pregnancy, without the presence of proteinuria or other organ dysfunction.

Choice C rationale:

Proteinuria is an expected finding in gestational hypertension. It is an important diagnostic criterion for preeclampsia, which is a severe form of gestational hypertension.

Choice D rationale:

Hepatic dysfunction is not an expected finding in uncomplicated gestational hypertension. Hepatic dysfunction would indicate more severe complications such as HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelet count), which is a medical emergency.

Choice E rationale:

Blood pressure usually returns to normal after pregnancy in women with uncomplicated gestational hypertension. However, it is essential to monitor the client closely postpartum to ensure blood pressure normalization.

A. Increased pancreatic activity during pregnancy causes fat intolerance. B. Increased estrogen production causes more hydrochloric acid in the stomach. C. Pressure from the growing uterus pushes up on the stomach and intestines. D. Progesterone causes relaxation of the cardiac sphincter allowing acid to reflux.

Correct Answer is D

Explanation

Choice A rationale:

Increased pancreatic activity during pregnancy causing fat intolerance is not related to the cause of indigestion and heartburn. Pancreatic activity can change during pregnancy, but it does not directly impact indigestion and heartburn.

Choice B rationale:

Increased estrogen production causing more hydrochloric acid in the stomach is not the cause of indigestion and heartburn during pregnancy. While hormones can influence digestion, the mechanism for indigestion and heartburn lies elsewhere.

Choice C rationale:

Pressure from the growing uterus pushing up on the stomach and intestines is a contributing factor to indigestion and heartburn during pregnancy. However, it is not the primary cause. The main cause is related to the relaxation of the cardiac sphincter.

Choice D rationale:

Progesterone causes relaxation of the cardiac sphincter, which is a muscular valve that prevents stomach acid from flowing back into the esophagus. When this sphincter relaxes, it can lead to acid reflux and subsequent indigestion and heartburn during pregnancy. The nurse should educate the client about this hormonal effect to help manage these symptoms effectively.

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A postpartum client's fundus is firm, 3 cm above the umbilicus, and displaced to the right. Which of the following interventions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with uncomplicated gestational hypertension. Which are expected findings of the disorder? Select all that apply.

Correct Answer is ["B","C"]

Explanation

A nurse is providing education to a client in the first trimester of pregnancy. What information should the nurse include regarding the cause of indigestion and heartburn?

Correct Answer is D

Explanation

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