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?

Encourage voiding

Notify healthcare provider

Inspect the perineal pad

Monitor vital signs

Answer and Explanation

The Correct Answer is A

Encourage voiding: A boggy uterus that is displaced above and to the right of the umbilicus often indicates that the bladder may be distended, which can push the uterus out of its normal position and prevent it from contracting properly. Encouraging the client to void can help to reduce bladder distension and allow the uterus to return to its normal position and firm up.

Notify healthcare provider: While this may ultimately be necessary if the problem persists or other complications are noted, the immediate action should be to address the most common cause of uterine displacement, which is bladder distension.

Inspect the perineal pad:
Checking the perineal pad can give clues about the amount of lochia (postpartum vaginal discharge). However, in this scenario, the priority lies in addressing the potential uterine atony.

Monitor vital signs:
While it's important to monitor vital signs, especially in postpartum clients, the priority here is recognizing and managing the potential uterine atony.

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Correct Answer is C

Explanation

A. Estimated amount of fluid:
Knowing the estimated amount of amniotic fluid can provide some information, but it may not be as crucial as other factors in this situation. The primary concern is often related to the color and odor of the amniotic fluid to assess for potential issues.

B. Color and consistency of fluid:
This is a crucial piece of information. The color and consistency of amniotic fluid can provide important clues about fetal well-being and the presence of meconium, which may indicate fetal distress.

C. Time the membranes ruptured:
Knowing the time when the membranes ruptured is essential for assessing the duration of time since the rupture. This information helps in determining the risk of infection, which is a concern after prolonged rupture of membranes.

D. Any odor noted when membranes ruptured:
This is also a critical piece of information. An unpleasant odor, especially if it is foul-smelling, could be indicative of infection. Infection risk increases with prolonged rupture of membranes.

A. Place the newborn in a position with the head lower than the feet. B. Turn the newborn to the side and bulb suction the mouth and nares. C. Wipe away the spit-up and assist the mother with the diaper change D. Sit the newborn upright and burp by rubbing or patting the upper back

Correct Answer is D

Explanation

A. Place the newborn in a position with the head lower than the feet:

This position might be used in cases of choking or difficulty breathing, but it's not typically the first response to spitting up.

B. Turn the newborn to the side and bulb suction the mouth and nares:

Suctioning might be necessary if there's difficulty breathing or if there's an excessive amount of mucus. However, for typical spit-up, this might be an unnecessary intervention.

C. Wipe away the spit-up and assist the mother with the diaper change:

Addressing the immediate concern by cleaning up and assisting with the diaper change is a reasonable first step, but it doesn't directly address the spit-up.

D. Sit the newborn upright and burp by rubbing or patting the upper back:

This is a common and appropriate action after feeding to help release any trapped air and prevent or alleviate spit-up.

Breastfeeding techniques and Burping Positions. | Download Scientific Diagram

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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

A client at 40-weeks gestation presents to the obstetrical floor and indicates that the amniotic membranes ruptured spontaneously at home. She is in active labor, and feels the need to bear down and push. Which information is most important for the nurse to obtain?

Correct Answer is C

Explanation

After breast-feeding 10 minutes at each breast, a new mother calls the nurse to the postpartum room to help change the newborn's diaper. As the mother begins the diaper change, the newborn spits up the breast milk. What action should the nurse implement first?

Correct Answer is D

Explanation

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