Which of the following findings should alert a nurse assessing a client who is 8 hr postpartum and multiparous?

Fundus three fingerbreadths above the umbilicus.

Moderate lochia rubra.

Blood pressure 130/84 mm Hg.

Moderate swelling of the labia.

Answer and Explanation

The Correct Answer is A

Choice A rationale
A fundus that is three fingerbreadths above the umbilicus 8 hours postpartum is a sign of urinary retention, which can displace the uterus and inhibit uterine contraction, leading to postpartum hemorrhage.
Choice B rationale
Moderate lochia rubra, or bloody discharge, is normal within the first few days after childbirth.
Choice C rationale
A blood pressure of 130/84 mm Hg is within the normal range for a postpartum woman.
Choice D rationale
Moderate swelling of the labia can be a normal finding after a vaginal birth.

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Correct Answer is A

Explanation

Choice A rationale
Late decelerations on the fetal monitor are a sign of fetal hypoxia, which means the baby is not getting enough oxygen. The priority nursing action is to position the client on her side, preferably the left side. This position improves blood flow to the uterus and the baby, potentially improving oxygenation.
Choice B rationale

Administering oxygen via face mask can also improve fetal oxygenation, but it is not the first action the nurse should take. Repositioning the client is a quicker intervention and often resolves the issue.
Choice C rationale
Elevating the client’s legs will not improve fetal oxygenation and is not a priority action when late decelerations are noted on the fetal monitor.
Choice D rationale
Increasing the infusion rate of the IV fluid can improve maternal blood volume and cardiac output, potentially improving blood flow to the uterus and the baby. However, it is not the first action the nurse should take when late decelerations are noted.

A. Massage the client’s back. B. Administer prescribed analgesic medication. C. Turn the client onto her left side. D. Encourage the client to rest between contractions.

Correct Answer is A

Explanation

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Which of the following findings should alert a nurse assessing a client who is 8 hr postpartum and multiparous?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is in active labor and notes late decelerations on the fetal monitor. Which of the following is the priority nursing action?

Correct Answer is A

Explanation

A nurse is caring for a client who is in labor. Which of the following nursing actions reflects application of the gate control theory of pain?

Correct Answer is A

Explanation

A nurse is providing preconception counseling for a client who is planning a pregnancy. Which of the following supplements should the nurse recommend to help prevent defects in the fetus?

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A nurse is examining a client who is in active labor and observes that the presenting part is in the left occiput posterior position. What is the clinical interpretation of this finding?

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