When assessing a multigravida on the first postpartum day, the nurse finds a moderate amount of lochia rubra, with the uterus firm and three fingerbreadths above the umbilicus. What action should the nurse implement first?
Check for a distended bladder.
Review the hemoglobin to determine hemorrhage.
Massage the uterus to decrease atony.
Increase intravenous infusion.
The Correct Answer is A
Choice B reason: Reviewing the hemoglobin to determine hemorrhage is an important action, but not the first one. The nurse should first identify and correct the cause of bleeding, such as bladder distension or uterine atony, before checking for blood loss and anemia.
Choice C reason: Massaging the uterus to decrease atony is not indicated in this case, because the uterus is already firm. Massaging a firm uterus can cause overstimulation and pain.
Choice D reason: Increasing intravenous infusion is not the first action, because it may worsen bleeding by increasing blood pressure and diluting clotting factors. The nurse should first assess and manage bleeding before administering fluids or blood products as prescribed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Marking an outline of the "olive-shaped" mass in the right epigastric area is not a priority nursing action. The mass is caused by hypertrophy of the pyloric sphincter, which obstructs gastric emptying and causes projectile vomiting. The mass may not be palpable in all cases.
Choice B reason: Instructing parents regarding care of the incisional area is a post-operative nursing action, not a pre-operative one. The parents will need to learn how to keep the incision clean and dry, monitor for signs of infection, and administer pain medication as prescribed.
Choice C reason: Monitoring amount of intake and infant's response to feedings is important, but not the highest priority. The infant may have difficulty feeding due to nausea, vomiting, and abdominal pain.
Correct Answer is ["A","E"]
Explanation
Choice A reason: Consuming foods with saturated fats can increase the level of low-density lipoprotein (LDL) cholesterol in the blood, which can contribute to plaque formation and narrowing of the coronary arteries.
Choice B reason: Walking 30 minutes per day can help lower blood pressure, improve blood circulation, and reduce the risk of heart attack and stroke.
Choice C reason: Using a salt substitute can help lower sodium intake, which can reduce fluid retention and lower blood pressure.
Choice D reason: Keeping a food diary can help the client monitor their calorie intake, portion size, and nutritional balance.
Choice E reason: Eating more canned vegetables can increase sodium intake, which can worsen fluid retention and blood pressure. Fresh or frozen vegetables are preferable.
Choice F reason: Including oatmeal for breakfast can provide soluble fiber, which can lower LDL cholesterol and prevent plaque formation in the coronary arteries.
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