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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Documenting the client's understanding is important, but correcting the misconception about the use of the eye drops is the immediate priority.
B. Reminding the client about the intended action of the eye drops helps clarify their purpose in managing glaucoma by reducing intraocular pressure.
C. Assessing the intensity of eye pain using a numerical pain scale might not be necessary in this context as the client's misconception about the eye drops needs correction.
D . Clarifying that eye pain in glaucoma is uncommon does not address the client's misunderstanding about the purpose of the pilocarpine eye drops.
Correct Answer is B
Explanation
A. Tell the UAP to take the client back to his room. - This action might not address the problem and may disrupt the ongoing activity without rectifying the situation.
B. Instruct the UAP to walk on the client's affected side. - When assisting a client with rightsided weakness, the caregiver should support the affected side, providing assistance and stability.
Instructing the UAP to walk on the client's affected side is the appropriate action.
C. Take over the ambulation and counsel the UAP later. - This might disrupt the ongoing care and might not rectify the situation immediately. Addressing it promptly is crucial.
D. Provide the client an assistive device, such as a cane or walker. - While assistive devices can be beneficial, in this scenario, the immediate concern is correcting the UAP's positioning
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