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 C

Explanation

A. Fluid replacement is important for maintaining maternal and fetal circulation, but it is not the priority immediately following a seizure. Oxygenation and stabilizing the mother’s condition are more critical in the acute phase.

B. Birth of the fetus may become necessary if the mother’s condition worsens, but the immediate priority is stabilizing the mother and ensuring proper oxygenation to prevent further complications for both the mother and fetus.

C. Oxygenation is the priority intervention after a seizure in eclampsia. Seizures can lead to a decrease in oxygen levels, and ensuring adequate oxygenation is crucial for both the mother and fetus. The nurse should administer oxygen to support breathing and prevent hypoxia.

D. Control of hypertension is essential in managing eclampsia, but the immediate focus should be on stabilizing the mother post-seizure, which includes ensuring adequate oxygenation first. Once stabilized, antihypertensive medications can be administered as necessary.

A. 8.4 mEq/L B. 6.1 mEq/L C. 10.8 mEq/L D. 3.3 mEq/L

Correct Answer is B

Explanation

A. 8.4 mEq/L is above the therapeutic range and may indicate magnesium toxicity. Levels greater than 7.5–8 mEq/L can lead to loss of deep tendon reflexes, and higher levels can cause respiratory depression and cardiac arrest.
B. 6.1 mEq/L falls within the therapeutic range for magnesium sulfate when used to treat severe preeclampsia, which is generally 4.8–8.4 mEq/L (or 4–7 mEq/L depending on the source and unit of measurement). This level is considered safe and effective for preventing seizures.
C. 10.8 mEq/L is too high and indicates magnesium toxicity, placing the patient at risk for serious complications like respiratory or cardiac arrest.
D. 3.3 mEq/L is below the therapeutic range, suggesting that the dose may be inadequate to prevent eclamptic seizures in a woman with severe preeclampsia.

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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 woman with gestational hypertension develops eclampsia and experiences a seizure. Which intervention would the nurse identify as the priority?

Correct Answer is C

Explanation

A woman is receiving magnesium sulfate as part of her treatment for severe preeclampsia. The nurse is monitoring the woman's serum magnesium levels. The nurse determines that the drug is at a therapeutic level based on which result?

Correct Answer is B

Explanation

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