The nurse is caring for a client who delivered 6 hours ago.
The client’s uterus is boggy and is displaced above and to the right of the umbilicus. What action should the nurse take?
Monitor the client’s vital signs.
Notify the healthcare provider.
Inspect the perineal pad.
Encourage the client to void.
The Correct Answer is D
Choice A rationale
While monitoring the client’s vital signs is an important part of postpartum care, it would not directly address the issue of a boggy uterus that is displaced above and to the right of the umbilicus.
Choice B rationale
Notifying the healthcare provider is important, but it would not be the first action to take. The nurse should first attempt to address the issue.
Choice C rationale
Inspecting the perineal pad could provide information about the client’s postpartum bleeding, but it would not directly address the issue of a boggy uterus that is displaced above and to the right of the umbilicus.
Choice D rationale
Encouraging the client to void is the correct action. A full bladder can displace the uterus, preventing it from contracting properly. By emptying the bladder, the uterus may be able to contract and return to its normal position.
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Related Questions
Correct Answer is B
Explanation
Choice A rationale
While monitoring vital signs is important in a client with eclampsia, it should be done more frequently than every 4 hours due to the risk of seizures and other complications.
Choice B rationale
Keeping an airway at the bedside is crucial for a client with eclampsia. If a seizure occurs, the airway can be used to ensure the client’s airway remains open.
Choice C rationale
Liberal family visitation may not be appropriate for a client with eclampsia who needs a quiet and stress-free environment to prevent triggering seizures.
Choice D rationale
Assessing temperature every hour is not specifically related to the care of a client with eclampsia.
Correct Answer is A
Explanation
Choice A rationale
Iron-deficiency anemia is a common nutritional issue among pregnant teenagers. During pregnancy, the body needs more iron to support the growth and development of the fetus. Teenagers, who are still growing themselves, may already have lower iron stores. Therefore, it is crucial to include information about the importance of iron and how to get enough from the diet in a nutrition education program for pregnant teenagers.
Choice B rationale
While gestational diabetes is a concern during pregnancy, it is not the most crucial topic for a nutrition education program specifically for pregnant teenagers. Gestational diabetes is a condition that can develop during pregnancy in women who don’t already have diabetes. It’s not as common in teenagers as it is in older women.
Choice C rationale
High cholesterol is generally not a primary concern during pregnancy. In fact, it’s normal for cholesterol levels to rise during pregnancy. However, long-term high cholesterol can increase the risk of heart disease.
Choice D rationale
Excessive weight gain can be a concern during pregnancy, but it is not the most crucial topic for a nutrition education program for pregnant teenagers. It’s normal and healthy to gain weight during pregnancy, but the amount should be carefully monitored. Excessive weight gain can lead to complications such as gestational diabetes or high blood pressure.
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