Thirty minutes after childbirth, a client's fundus is firm, shifted to the right of the midline above the umbilicus. Based on this finding, how will the nurse intervene?
Have the client void, then reassess the fundus.
Encourage the client to ambulate. to
Notify the healthcare provider.
Obtain an order for oxytocin.
The Correct Answer is A
A) Have the client void, then reassess the fundus:
A fundus that is firm but shifted to the right of the midline is a common sign of bladder distention. After childbirth, the bladder may fill with urine, which can displace the uterus and cause it to deviate from the midline, typically to the right. The first step in managing this situation is to have the client void to relieve the bladder distention, which often resolves the uterine shift. Once the bladder is empty, the nurse should reassess the fundus to see if the position returns to midline and remains firm. This is a non-invasive and effective initial intervention.
B) Encourage the client to ambulate:
Encouraging the client to ambulate could be beneficial for overall recovery, but it is not the priority action in this case. The issue at hand is a shifted fundus likely due to bladder distention, which should be addressed by encouraging the client to void first. Ambulation can be considered later when the immediate concern of bladder distention is managed.
C) Notify the healthcare provider:
While notifying the healthcare provider may be necessary if the issue persists after voiding or if there are other signs of complications, it is not the first step. The nurse should first attempt to resolve the issue through bladder emptying, as this is the most common cause of the shift in the fundus. If the problem persists after this, then further steps, including notifying the healthcare provider, would be appropriate.
D) Obtain an order for oxytocin:
Oxytocin is typically administered to help with uterine contraction and involution. However, since the fundus is firm and the primary issue appears to be bladder distention, administering oxytocin is not indicated at this time. The priority is to address the likely cause of the fundus being shifted, which is a full bladder. If the issue persists after voiding, then further intervention such as administering oxytocin may be considered.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) The neonate with respirations of 78 and a heart rate of 176:
This is the most concerning finding and requires immediate evaluation. Normal respiratory rate for a newborn is typically between 30 and 60 breaths per minute, so a rate of 78 breaths per minute is significantly elevated, indicating potential respiratory distress. Additionally, a heart rate of 176 beats per minute, while somewhat elevated, could indicate tachycardia, especially if the baby is experiencing distress or inadequate oxygenation. This combination of abnormal vital signs may point to respiratory or cardiovascular compromise, such as respiratory distress syndrome or other neonatal respiratory issues, which requires immediate evaluation and intervention.
B) The neonate with a temperature of 99.1°F and a weight of 3000 grams:
This neonate’s temperature is within the normal range (97.7°F to 99.5°F), and a weight of 3000 grams is also considered appropriate for a full-term newborn. These findings do not raise any immediate concerns, and no further action is necessary based on these observations alone.
C) The neonate with raised white specks on the gums:
Raised white specks or nodules on the gums are often a normal finding in newborns and are called Epstein pearls. These are benign cystic formations that do not require treatment. They are not a cause for concern and are common in newborns, usually disappearing on their own within a few weeks.
D) The neonate with white spots on the bridge of the nose:
White spots on the nose are likely to be Milia, which are small, benign cysts commonly seen on the face of newborns, particularly on the nose, cheeks, and chin. Milia are harmless and typically resolve without treatment within a few weeks. There is no need for concern in this case.
Correct Answer is ["4"]
Explanation
The Apgar score is calculated based on five criteria, each scored from 0 to 2:
-
Heart rate
- 0 = Absent
- 1 = Below 100 beats per minute ✅
- 2 = 100 or more beats per minute
-
Respiratory effort
- 0 = Absent
- 1 = Slow, irregular ✅
- 2 = Good, crying
-
Muscle tone
- 0 = Limp
- 1 = Some flexion of extremities ✅
- 2 = Active motion
-
Reflex irritability (response to stimulation, e.g., suctioning)
- 0 = No response
- 1 = Grimace ✅
- 2 = Crying, active withdrawal
-
Color
- 0 = Blue, pale
- 1 = Body pink, extremities blue
- 2 = Completely pink
Apgar Score Calculation:
- Heart rate: 1
- Respiratory effort: 1
- Muscle tone: 1
- Reflex irritability: 1
- Color: 0
Total Apgar Score: 4
A score of 4 suggests the newborn is in distress and requires immediate medical intervention, such as oxygen support and further assessment.
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