The nurse is caring for a postpartum client who delivered vaginally 4 hours ago.
The client has a fundal height of 2 fingerbreadths above the umbilicus and is deviated to the right.
What is the priority nursing action?
Immediately notify the healthcare provider.
Assist the client to empty their bladder.
Administer intravenous pain medications.
Insert a sterile foley catheter.
The Correct Answer is B
Managing the immediate postpartum period requires applying knowledge of uterine involution and the anatomical relationship between the bladder and uterus. Nurses must recognize how bladder distention affects uterine placement and the subsequent risk of hemorrhage from uterine atony.
Choice A rationale
Notifying the healthcare provider is not the initial step because the clinical findings are characteristic of a full bladder rather than a primary medical emergency. Correcting the bladder distention should occur first to assess if the fundus returns.
Choice B rationale
A full bladder displaces the uterus upward and to the right, preventing effective contraction. Assisting the client to void resolves the displacement, allows the fundus to descend, and promotes uterine contraction, which is the priority to prevent postpartum hemorrhage.
Choice C rationale
Pain medications do not address the physiological cause of a high, deviated fundus. While the client may have discomfort, the priority is mechanical correction of the bladder to ensure uterine safety and prevent excessive bleeding from atony.
Choice D rationale
While a catheter might be needed if the client cannot void, it is more invasive. The nurse should first attempt to assist the client to the bathroom or provide a bedpan before resorting to sterile catheterization.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
This prenatal scenario involves applying knowledge of human embryology and fetal development stages. Identifying the specific terminology and physiological milestones at 6 weeks gestation is necessary to provide accurate education regarding the transition from the pre-embryonic to the embryonic period.
Choice A rationale
A blastocyst refers to the stage of development approximately 5 to 10 days after fertilization, during implantation. By 6 weeks gestation, the pregnancy has progressed significantly past this initial pre-embryonic stage of germ layer formation.
Choice B rationale
At 6 weeks gestation, the product of conception is called an embryo. This period, spanning weeks 3 through 8, is characterized by rapid organogenesis, where all major organ systems are established and highly vulnerable to teratogens.
Choice C rationale
The term fetus is used starting at the ninth week of gestation until birth. While the embryo is developing human characteristics at 6 weeks, it is not yet classified as a fetus in medical terminology.
Choice D rationale
A morula is a solid ball of cells that exists around day 3 or 4 after fertilization as it travels through the fallopian tube. This stage occurs long before the 6-week prenatal visit..
Correct Answer is D
Explanation
Evaluating a late-preterm client with bleeding and contractions requires knowledge of maternal-fetal triage. Priority is given to assessing fetal well-being and uterine activity to differentiate between labor, placental abruption, or other complications, ensuring the safety of both patients.
Choice A rationale
Digital cervical examinations are contraindicated until the location of the placenta is confirmed via ultrasound. If placenta previa is present, manual assessment can cause catastrophic maternal hemorrhage. Physical assessment must follow the stabilization of fetal and maternal monitoring.
Choice B rationale
Immediate delivery preparation is premature without a confirmed diagnosis. While 36 weeks is near term, the cause of bleeding must be identified first. Delivery may be necessary for abruption, but monitoring is the initial step to determine urgency.
Choice C rationale
Tocolytics are used to delay labor, but they are contraindicated in cases of significant vaginal bleeding or suspected placental abruption. Administering these before confirming the cause of bleeding could mask worsening clinical signs and delay necessary interventions.
Choice D rationale
Applying an external monitor is the priority to evaluate fetal heart rate patterns and uterine contraction frequency. This non-invasive step provides immediate data on fetal distress, which is critical when vaginal bleeding suggests potential placental or cord issues.
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