Four hours postpartum, the nurse notes the uterus is firm but displaced to the right.
The client voided 150 mL one hour ago and feels pressure in her bladder.
What should the nurse do first?
Document and reassess in one hour.
Administer intravenous pain medication.
Massage the fundus.
Encourage the client to void again.
The Correct Answer is D
Choice A rationale
While documentation is essential, it should follow the initial intervention to correct the displacement and pressure. Reassessing in one hour is inappropriate because a firm but displaced uterus, combined with a sensation of bladder pressure despite a recent small void (150 mL is generally considered a small volume in this context), strongly indicates a distended bladder is preventing the uterus from contracting effectively and remaining midline.
Choice B rationale
Administering intravenous pain medication does not address the underlying issue of uterine displacement and potential bladder distension. A full bladder is a priority concern as it significantly impedes uterine involution and increases the risk of excessive postpartum bleeding (hemorrhage). Pain relief is secondary to ensuring uterine stability and hemostasis.
Choice C rationale
Massaging a fundus that is already firm will not correct the issue of displacement caused by a full bladder and can cause unnecessary discomfort. The priority intervention is to empty the bladder to allow the uterus to return to the midline, contract efficiently, and reduce the risk of bleeding. The uterus is firm, suggesting good tone, but its position is compromised.
Choice D rationale
The most likely cause of a firm but displaced uterus (to the right) and the client's reported bladder pressure is urinary retention or a full bladder, even though she recently voided a small amount. An overdistended bladder prevents the uterus from contracting effectively and returning to the midline. Encouraging the client to void again, or assisting with catheterization if necessary, is the essential first step to allow the uterus to contract properly and centrally. —.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Teaching proper latch and positioning is the most effective intervention for nipple soreness, as the primary cause is often shallow latching or improper positioning, leading to trauma. A deep, symmetrical latch covering a large portion of the areola ensures the nipple is positioned correctly at the back of the newborn's mouth, reducing friction and pain.
Choice B rationale
Keeping nipples covered between sessions, especially with non-breathable materials, can trap moisture and increase the risk of fungal infections like candidiasis, potentially worsening soreness. Air drying after feedings and wearing cotton bras are generally preferred to promote healing and hygiene.
Choice C rationale
Applying petroleum jelly is generally not recommended as it does not promote healing for soreness caused by trauma and may block the pores on the nipple and areola. Lanolin or hydrogel pads are better options because they create a moist healing environment and are safe for ingestion by the newborn.
Choice D rationale
Advising a mother to stop breastfeeding until soreness resolves is counterproductive, as sudden cessation can cause milk engorgement and may jeopardize the continuation of breastfeeding. Temporary soreness can be managed by optimizing technique and ensuring the newborn feeds well to maintain milk flow.
Correct Answer is A
Explanation
Choice A rationale
Convection is the heat loss mechanism that involves the transfer of heat from the infant's skin surface to the surrounding cooler air currents. The draft from the open window and the movement of air in the room facilitate this rapid movement of heat away from the infant's body, causing a significant and quick drop in the core temperature, especially when the infant is wet from bathing.
Choice B rationale
Evaporation is the loss of heat that occurs when water (like amniotic fluid or bath water) on the infant's skin surface is converted into vapor. Although this is a significant form of heat loss during and immediately after bathing, the additional factor of a "drafty room near an open window" strongly suggests that convection is the primary or most significant cause of the heat loss in this specific scenario.
Choice C rationale
Conduction involves the transfer of heat from the infant to a cooler object that is in direct contact with the skin, such as a cold scale, mattress, or towel. In this scenario, while the bath setup could involve some conduction, the presence of a drafty room and open window makes heat loss via convection a far more pronounced and likely cause for the significant temperature drop.
Choice D rationale
Radiation is the transfer of heat from the infant's warmer body surface to nearby cooler solid objects that are not in direct contact with the skin, such as cold walls or windowpanes. Although the open window may be a cool object, the draft (moving air) explicitly described in the situation points more directly to heat loss through air currents, which is defined as convection.
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