The nurse is caring for a client who delivered 6 hours ago. Assessment findings reveal a boggy uterus that is displaced above and to the right of the umbilicus. Which action should the nurse take?

Inspect the perineal pad.

Encourage voiding.

Monitor vital signs.

Notify healthcare provider.

Answer and Explanation

The Correct Answer is B

A. Inspect the perineal pad: While it is important to assess for bleeding, the primary concern in this scenario is the displaced and boggy uterus, which suggests the need to address potential bladder distention.

B. Encourage voiding: A boggy, displaced uterus, particularly if it is to the right and above the umbilicus, is often a sign of bladder distention. Encouraging the client to void will help relieve bladder pressure on the uterus, allowing it to contract properly and reduce the risk of hemorrhage.

C. Monitor vital signs: Vital signs should always be monitored, but addressing the underlying cause of the boggy and displaced uterus (bladder distention) is a more immediate priority to prevent complications such as postpartum hemorrhage.

D. Notify healthcare provider: While notifying the healthcare provider is important if the problem persists, the nurse should first address bladder distention by encouraging the client to void. This may resolve the issue without the need for further intervention.

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Correct Answer is B

Explanation

A. Re-evaluate the need for medication: While it's important to reassess the client's pain management preferences, the primary focus for an unmedicated delivery is to provide support and help the client cope with labor without the use of medications.
B. Assisting her to maintain control: The primary focus during the active phase of labor for an unmedicated delivery is helping the client maintain control over her body and manage the pain through non-pharmacological methods. This could include breathing techniques, relaxation, and positioning.
C. Assessing the strength of uterine contractions: While monitoring contractions is essential for assessing labor progress, the focus should be more on providing emotional support and ensuring the client is empowered to manage the pain without medication.
D. Remind her to push three times with each contraction: Pushing instructions are typically given in the second stage of labor, not the active phase. During the active phase, the client is usually focusing on coping with the contractions.

A. One-hour glucose screen. B. Repeat HIV test. C. Multiple marker screening. D. Direct Coombs' test.

Correct Answer is A

Explanation

A. One-hour glucose screen: The one-hour glucose screen is typically performed at 24-28 weeks gestation to screen for gestational diabetes. This is a standard test for all pregnant women during this time frame, regardless of ethnicity, and should be included in the client teaching.
B. Repeat HIV test: While HIV screening is important during pregnancy, a repeat HIV test at 28 weeks is not typically recommended for all women unless they are at high risk or have specific risk factors.
C. Multiple marker screening: This screening is usually done earlier in pregnancy, typically between 15-20 weeks, to assess the risk of certain fetal conditions like Down syndrome and neural tube defects. It is not performed at 28 weeks.
D. Direct Coombs' test: The Direct Coombs' test is typically performed on newborns, not on pregnant women, to check for hemolytic disease. However, Rh-negative women are often screened with the indirect Coombs' test at 28 weeks to check for antibodies, not the direct Coombs' test.

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Body System	Nurses Notes and Flow Sheet
Respiratory	Respirations 16 breaths/minute Oxygen saturation of 89% Several deep breaths
Integumentary	Episiotomy intact with no redness Pad is saturated with blood 18 gauge IV to left forearm
Circulatory	Heart rate 96 beats/minute Blood pressure 90/62 mm Hg IV infusing at 125 mL/hr
Genital/Urinary	Boggy fundus 1 cm above umbilicus Fundus rotated to the right Voided 200 mL of clear yellow urine

The nurse is caring for a client who delivered 6 hours ago. Assessment findings reveal a boggy uterus that is displaced above and to the right of the umbilicus. Which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which should be the primary focus of nursing care in the active phase of labor for a client who anticipates an unmedicated delivery?

Correct Answer is B

Explanation

The nurse is providing anticipatory guidance for an African-American client who is at 24-weeks gestation. Which prenatal laboratory assessment, prescribed at 28-weeks, should the nurse include in client teaching?

Correct Answer is A

Explanation

How should the nurse plan to position a client who has just undergone a radical mastectomy?

The nurse is caring for a client who delivered 6 hours ago. Assessment findings reveal a boggy uterus that is displaced above and to the right of the umbilicus. Which action should the nurse take?

The nurse is initiating an interview with a client in the emergency department (ED) who presents with a fractured ulna and swollen, red lips and nose. The client's spouse is pacing outside the door of the examination room. Which action should the nurse take?

A woman who delivered a normal newborn 24 hours ago reports, "I seem to be urinating every hour or so. Is that OK? Which action should the nurse implement?

Exhibits Which education by the nurse will help resolve the issue for the client? Select all that apply.

Exhibits The nurse reviews the client's history and physical, the nurses' notes, and the flow sheet. Select the findings that will help the nurse determine which is causing the client's symptoms.