The practical nurse (PN) 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 PN take?
Encourage voiding.
Monitor vital signs.
Notify healthcare provider.
Inspect the perineal pad.
The Correct Answer is A
If the practical nurse (PN) is caring for a client who delivered 6 hours ago and assessment findings reveal a boggy uterus that is displaced above and to the right of the umbilicus, the PN should encourage the client to void. A full bladder can displace the uterus and prevent it from contracting properly, leading to a boggy uterus. Encouraging the client to void can help empty the bladder and allow the uterus to contract and return to its normal position. The other actions listed may also be appropriate in some situations, but encouraging voiding is the most appropriate action in this situation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
An increasing trend in maternal heart rate is a sign of fetal distress, which can be a serious complication of PROM. One of the primary interventions for fetal distress is to increase oxygen delivery to the fetus. The practical nurse should initiate oxygen via face mask at 8 to 10 L/min to improve fetal oxygenation.
Contact precautions may be necessary for certain conditions, but they are not indicated for an increasing maternal heart rate.
Inserting a urinary catheter may be appropriate for monitoring output, but it is not the first priority in this situation.
Encouraging the client to push is not appropriate because the client is not in active labor and pushing can cause further complications.
Correct Answer is A
Explanation
The practical nurse (PN) should obtain information about the client's current medications, including any analgesics or antianxiety medications that may be contributing to the confusion. These medications can cause cognitive impairment and confusion, especially in older adults. It is important to assess the client's mental status and identify any potential causes of confusion, as this can indicate a change in the client's condition that requires further evaluation and intervention.
Option B is incorrect as it refers to a history of situational depression, which may not be relevant to the current situation.
Option C is also incorrect as it refers to previous falls, which may not be related to the current confusion.
Option D is incorrect as it refers to the client's history of alcohol abuse, which may be important to know but is not the most relevant information to obtain in this situation.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today