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 A

Explanation

A. Elevated liver enzymes is a key indicator of HELLP syndrome, which stands for Hemolysis, Elevated Liver enzymes, and Low Platelets. HELLP syndrome is a severe form of preeclampsia and can lead to liver damage. Elevated liver enzymes, such as AST and ALT, are a hallmark of this condition, indicating liver dysfunction.

B. Elevated platelet count would be the opposite of what is expected in HELLP syndrome. In HELLP syndrome, there is typically low platelet count (thrombocytopenia), not an elevated one.

C. Leukocytosis refers to an increased white blood cell count, which can be indicative of an infection or inflammation, but it is not a hallmark of HELLP syndrome. HELLP syndrome primarily involves hemolysis, liver enzyme elevation, and low platelets.

D. Hyperglycemia is not a characteristic finding of HELLP syndrome. While it can occur in some pregnancy-related conditions, it is not specifically associated with HELLP syndrome. This condition is more associated with elevated liver enzymes and low platelets.

A. 25mg/hr B. 25g/hr C. 250ml/hr D. 25ml/hr

Correct Answer is D

Explanation

A. 25mg/hr is incorrect. The question asks for the volume in mL/hr, not the dose in milligrams per hour.
B. 25g/hr is incorrect. The ordered dose is 1g/hr, not 25g/hr.
C. 250mL/hr would provide a much higher dose than ordered, based on the concentration.
D. 25mL/hr is correct. This is the calculated volume to deliver the 1g/hr maintenance dose based on the supplied concentration. Volume= Ordered dose/ Concentration

Determine the concentration of the solution: The supplied concentration is 20g/500mL, which simplifies to 0.04g/mL (since 20g = 20,000mg and 500mL = 500mL).

Determine the ordered dose: The order is for a maintenance dose of 1g/hr.

Calculate the volume to be infused: 1/0.04= 25mL/hr

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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?

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Naxlex Comprehensive Predictor Exams

The nurse is reviewing the laboratory test results of a pregnant client. Which finding would alert the nurse to the development of HELLP syndrome?

Correct Answer is A

Explanation

The nurse is caring for a client receiving Magnesium Sulphate. The loading dose has already been given and the maintenance dose order reads 1g/hr. The drug is supplied 20g/500ml Solve the maintenance dose to be given in ml/hr

Correct Answer is D

Explanation

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