The practical nurse (PN) determines that a client who is one day postpartum has a moderate amount of lochia rubra and the uterus is firm, dextroverted, and three fingerbreadths above the umbilicus. Which should be the PN's initial action?

Provide a stool softener for constipation.

Assess the bladder for distension.

Check the hemoglobin to determine uterine hemorrhage.

Massage the uterus to decrease atony.

Answer and Explanation

The Correct Answer is B

Correct Answer: B.
A.   Providing a stool softener for constipation might be necessary postpartum but isn't the initial action indicated by the client's current status.
B.   Assessing the bladder for distension is crucial because a distended bladder can displace the uterus and impede its ability to contract properly, leading to uterine atony and increased bleeding.
C.   Checking the hemoglobin to determine uterine hemorrhage is important but might not be the initial step needed based on the client's condition.
D.   Massaging the uterus to decrease atony is a potential intervention, but assessing for bladder distension takes priority in this scenario to prevent uterine displacement.

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Correct Answer is C

Explanation

A. Assess her feelings about therapeutic abortions in the event the infant has been affected. - While important to address concerns, the immediate priority is to manage the current outbreak and prevent transmission.
B. Identify current sexual partners so that they can be evaluated and treated for genital herpes if necessary. - Contact tracing is important but not the highest priority in managing the current outbreak.
C. Instruct her to avoid sexual intercourse while active, visible lesions are present. - This is crucial to prevent transmission of the herpes virus to the sexual partner and to reduce the risk of complications for the pregnancy.
D. Determine if the client has taken acyclovir for this outbreak of genital herpes. - While important for understanding the treatment history, instructing the client on preventive measures has a higher priority.

A. Determine the means by which residents will be evacuated. B. Close all fire doors and the doors to all the residents' rooms. C. Assist any wandering residents back to their rooms. D. Offer comfort and reassurance to distraught residents.

Correct Answer is A

Explanation

A. Determine the means by which residents will be evacuated. - This task requires critical decision-making and understanding of evacuation protocols, which is within the scope of the practical nurse's responsibilities.
B. Close all fire doors and the doors to all the residents' rooms. - While important for containment, this can be executed by UAP following established protocols.
C. Assist any wandering residents back to their rooms. - UAP can assist in guiding residents back to their rooms safely.
D. Offer comfort and reassurance to distraught residents. - Both PN and UAP can offer comfort and reassurance to residents during such situations.

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The practical nurse (PN) determines that a client who is one day postpartum has a moderate amount of lochia rubra and the uterus is firm, dextroverted, and three fingerbreadths above the umbilicus. Which should be the PN's initial action?

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Naxlex Comprehensive Predictor Exams

During the first trimester of pregnancy, a client who was treated for genital herpes with acyclovir prior to this pregnancy tells the practical nurse (PN) that she is experiencing an episode of genital herpes. Which nursing intervention has the highest priority?

Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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