On completing fundal palpation, the nurse notes that the fundus is located to the right side of the abdomen.
Which action is appropriate?
Ask the client to empty her bladder.
Straight-catheterize the client immediately.
Call the client's primary health care provider for direction.
Straight-catheterize the client for half of her urine volume.
The Correct Answer is A
Choice A rationale
A fundus located to the right side of the abdomen (a lateral deviation) and potentially higher than expected is the classic sign of a distended bladder. A full bladder physically displaces the uterus from its normal midline, contracted position, which also hinders effective uterine muscle contraction (atony), increasing the risk of postpartum hemorrhage. The first appropriate, least invasive action is to ask the client to empty her bladder.
Choice B rationale
Straight-catheterizing the client immediately is an invasive procedure and is generally reserved for situations where the client is unable to void voluntarily after other measures, like position changes or running water, have been attempted. It is not the initial, least-risk intervention for a displaced fundus, as the client may be able to void naturally.
Choice C rationale
Calling the client's primary health care provider for direction is unnecessary as the nurse's assessment findings point clearly to a common, manageable postpartum issue: bladder distension causing uterine displacement. The appropriate, evidence-based nursing protocol is to first attempt to have the client void spontaneously to correct the displacement.
Choice D rationale
Straight-catheterizing the client for half of her urine volume is not a standard procedure. If catheterization becomes necessary because the client cannot void, the goal is to fully empty the bladder to relieve the pressure and allow the uterus to contract properly. Only complete bladder emptying will effectively resolve the uterine displacement and reduce hemorrhage risk.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Step 1 is: Determine the ordered daily dosage. The order is 500 mg po q hours, which is four doses per day (24 hours÷ 6 hours = 4). 500 mg/dose× 4 doses/24 h = 2000 mg/24 h.
Step 2 is: Compare the ordered daily dosage (2000 mg/24 h) to the calculated safe daily dosage range (500 mg/24 h to 1000 mg/24 h from. 2000 mg/24 h is greater than 1000 mg/24 h. Based on the calculated safe range, the dose is 𝐮𝐧𝐬𝐚𝐟𝐞.
Correct Answer is B
Explanation
Choice A rationale
Isolating oneself by staying home is contraindicated as it can exacerbate feelings of loneliness and isolation, which are significant features of postpartum depression (PPD). Social support and interaction are crucial components of recovery and mental well-being for a client with a history of PPD, and social engagement is actively encouraged for a positive prognosis.
Choice B rationale
Regular contact with a mental health professional or crisis counselor is a critical component of the management plan for a client at high risk for or experiencing PPD. This provides ongoing assessment, emotional support, and therapeutic intervention, ensuring early detection of worsening symptoms and facilitating timely, effective mental health care, thereby reducing the risk of a severe depressive episode.
Choice C rationale
Returning to work within two weeks post-delivery is premature and can increase stress and fatigue, which are triggers for PPD symptoms. The recommended postpartum recovery period typically extends to six weeks or more, allowing for physical healing and psychological adjustment to the demands of motherhood before resuming external professional obligations.
Choice D rationale
While adequate sleep is vital to combat the fatigue associated with new motherhood, which is a known PPD trigger, instructing the client to "sleep as much as possible" is unrealistic and potentially isolating. PPD management focuses on balanced self-care, ensuring rest while maintaining necessary activities, social engagement, and adherence to the mental health treatment plan.
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