During a routine postpartum assessment following a normal vaginal delivery, the nurse notes the fundus is firm, but the level has changed from U-1 to U+1 and deviated to the left. Which action would be appropriate before continuing the assessment?

Request the client to empty her bladder

Follow PRN order to insert a straight urinary catheterization

Start an IV and add 20 units Pitocin

Massage fundus until it descends below the level on umbilicus.

Answer and Explanation

The Correct Answer is A

A. Request the client to empty her bladder is the correct action. A fundus that is firm but deviated to the left and higher than expected (U+1) suggests that the bladder is full. A full bladder can displace the uterus, causing it to become misaligned and elevated. Asking the client to empty her bladder is often the first step to address this situation before proceeding with further assessment or intervention.

B. Follow PRN order to insert a straight urinary catheterization might be appropriate if the client is unable to empty her bladder voluntarily, but it is typically a last resort. Before resorting to catheterization, encourage the client to try to void first.

C. Start an IV and add 20 units Pitocin would be indicated if there were signs of uterine atony or hemorrhage. However, in this case, the issue seems related to bladder distention rather than uterine atony, so starting Pitocin is not the appropriate immediate response.

D. Massage fundus until it descends below the level of the umbilicus would be done if the fundus were boggy or soft, indicating uterine atony. However, in this case, the fundus is described as firm, so massaging is not necessary. The priority is addressing the bladder distention.

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Correct Answer is D

Explanation

A. Increase in dietary protein is not the appropriate response based on the results of the glucose challenge test. Protein intake may be adjusted for other health reasons but is not typically a first-line intervention after an abnormal GCT result.

B. Schedule a repeat Glucose Challenge Test (GCT) is not typically the next step. If the initial GCT is abnormal (usually a result >130-140 mg/dL), a repeat test is not recommended. Instead, a 3-hour glucose tolerance test (GTT) is used to confirm or rule out gestational diabetes.

C. Restrict carbohydrate intake might be part of managing gestational diabetes if it is diagnosed, but it is not the immediate next step after an abnormal GCT result. The focus is on further testing with a 3-hour GTT to confirm gestational diabetes.

D. Return for a fasting 3-hour glucose tolerance test (GTT) is the correct next step. If a client’s GCT result is ≥130-140 mg/dL, a 3-hour GTT is typically scheduled. The 3-hour GTT is a more comprehensive test that involves fasting and measuring blood glucose levels after consuming a larger dose of glucose (100 g). This test is used to diagnose gestational diabetes.

A. 7 B. 8 C. 5 D. 9

Correct Answer is D

Explanation

A. A score of 7 would be given if the infant’s heart rate was 100, but with less than optimal responses for color, muscle tone, and respiratory effort. However, this baby demonstrates strong responses in all categories.

B. A score of 8would indicate that the baby has no signs of cyanosis and perfect responses in all categories, but since the infant has blue hands, it scores slightly lower (1 point less for color).

C. A score of 5 would indicate more significant distress, with poor color, respiratory effort, and muscle tone. This infant is showing good signs of adaptation.

D. The Apgar score is calculated based on five criteria: heart rate, respiratory effort, muscle tone, reflex irritability, and color. The infant in the scenario has:Heart rate of 100 (score 2)Pink body and blue hands (score 1 for color—because the baby is not fully pink, indicating some cyanosis in the extremities)Active motion (score 2 for muscle tone)Strong lusty cry (score 2 for reflex irritability/responsiveness to stimuli)
Good respirations (score 2)Adding these scores (2 + 1 + 2 + 2 + 2), the total is 9.

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During a routine postpartum assessment following a normal vaginal delivery, the nurse notes the fundus is firm, but the level has changed from U-1 to U+1 and deviated to the left. Which action would be appropriate before continuing the assessment?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A 26-week pregnant client has a Glucose challenge test (GCT) with 50 g of glucola, her results are 150mg/dl. What would be expected next step when caring for this client?

Correct Answer is D

Explanation

The nurse is performing an Apgar score on a newborn at 5 minutes after birth. The infant has a heart rate of 100, pink body and blue hands, active motion, and a strong lust cry and respirations. What is the Apgar score that should be assigned to this infant?

Correct Answer is D

Explanation

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