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","D","E"]

Explanation

A. Place client in a negative pressure room:HIV is not an airborne disease, and clients with HIV do not require isolation in a negative pressure room. Standard precautions are sufficient to prevent transmission.

B. Implement droplet precautions:HIV is not transmitted via droplets. It is transmitted through contact with blood, certain body fluids, or perinatal exposure. Droplet precautions are not indicated.

C. Encourage the mother to bottle-feed: HIV can be transmitted through breast milk. To prevent vertical transmission postpartum, mothers with HIV are advised to avoid breastfeeding and to use formula or bottle-feed instead.

D. Give antiviral medication intravenously: Intrapartum IV zidovudine should be administered in the following situations: (a) HIV RNA >1,000 copies/mL, (b) unknown HIV RNA, (c) known or suspected lack of adherence since the last HIV RNA result, or (d) a positive expedited antigen/antibody HIV test result during labor (AI).

E. Use standard precautions:Standard precautions are the appropriate infection control measures for caring for clients with HIV. This includes wearing gloves, practicing proper hand hygiene, and avoiding contact with the client's blood and other potentially infectious fluids.

A. Instruct the client to maintain bed rest for 24 hours. B. Encourage the client to increase her intake of oral fluids C. Schedule a visit with the healthcare provider today D. Verify the administered Rho(D) immune globulin's compatibility

Correct Answer is C

Explanation

A. Instruct the client to maintain bed rest for 24 hours:
There is no clear indication for bed rest based solely on a slightly elevated temperature. Bed rest is not a standard recommendation for this situation.

B. Encourage the client to increase her intake of oral fluids:
Increasing fluid intake is a general recommendation for mild elevations in temperature. Adequate hydration can support the body's natural response to infection or inflammation.

C. Schedule a visit with the healthcare provider today:
This option is a prudent choice. A temperature elevation after a medical procedure may indicate an infection, and it's appropriate to schedule a visit with the healthcare provider for further evaluation.

D. Verify the administered Rho(D) immune globulin's compatibility:
While verifying the compatibility of the administered medication is important, it is not the primary concern when a client reports an elevated temperature. In this context, addressing the temperature and potential infection takes precedence.

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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 is admitted in active labor, and laboratory findings indicate that she is HIV positive. Which actions should the nurse plan to perform? (Select all that apply.)

Correct Answer is ["C","D","E"]

Explanation

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Correct Answer is C

Explanation

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