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 E
Explanation
A) Bulb syringe in crib:
While a bulb syringe can be useful for clearing the infant’s airway in case of respiratory distress, keeping it in the crib is not an optimal safety practice. The syringe should be readily available but not within reach of the infant, as it could be a choking hazard if mishandled. Ideally, it should be stored in an easily accessible area but not within the crib.
B) Secure hugs tag on and alarms activated:
Ensuring that the infant has a security tag (often referred to as a "Hugs" tag) that is properly placed and that alarms are activated is an important safety measure to prevent infant abductions. Hospitals typically use electronic security systems that alert staff if the infant is removed from the designated area without proper authorization. This intervention is essential for maintaining safety in the hospital setting.
C) ID bands match with mom's ID bands:
It is critical that the infant's ID band matches the mother's ID band. This helps prevent any mix-up or baby swap and ensures that the infant is properly identified at all times. Regular checks should be made to verify that the bands match and remain secure throughout the hospital stay.
D) Infant on their back to sleep:
Placing the infant on their back to sleep is a key guideline for reducing the risk of Sudden Infant Death Syndrome (SIDS). This position has been proven to be the safest for infants and is a crucial practice for their well-being. Educating parents and caregivers about safe sleep practices is vital for infant safety.
E) All of the above:
All of these practices are part of a comprehensive safety plan for the infant. Ensuring that the infant is safely secured with proper identification, preventing any risk of abduction, promoting safe sleep practices, and ensuring that airway equipment is available are all essential measures in maintaining the safety of the newborn. Therefore, the correct response is "All of the above."
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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