Within 3 hours, the fundus becomes boggy and is located 2 cm above the umbilicus and displaced to the right in the postpartum patient.
What is the priority nursing action?
Inform the obstetrician.
Straight catheterize the patient.
Prepare the patient for manual removal of uterine clots.
Ask the patient to void.
The Correct Answer is D
Choice A rationale
Informing the obstetrician is important, but it is not the first action to take. The nurse should first try to address the issue at hand, which is a displaced and boggy uterus.
Choice B rationale
Straight catheterization of the patient could be necessary if the patient is unable to void. However, the first step should be to ask the patient to void.
Choice C rationale
Preparing the patient for manual removal of uterine clots is a more invasive procedure that should be considered if other measures, such as asking the patient to void or massaging the fundus, are not effective.
Choice D rationale
A full bladder can displace the uterus and prevent it from contracting properly. Asking the patient to void can help the uterus contract and reduce bleeding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Notifying the clinician immediately may be necessary, but it is not the first action to take. The nurse should first identify the cause of the baby’s symptoms.
Choice B rationale
The baby’s symptoms are indicative of hypoglycemia, a common condition in infants of mothers with diabetes. Testing the blood glucose level would confirm this diagnosis and allow for appropriate treatment.
Choice C rationale
Starting an intravenous line with D5W may be necessary if the baby’s blood glucose level is low. However, the first step should be to confirm the diagnosis by testing the blood glucose level.
Choice D rationale
Documenting the event in the nurse’s notes is important, but it is not the first action to take. The nurse should first address the baby’s immediate needs.
Correct Answer is C
Explanation
Choice A rationale
Atelectasis, or collapse of part or all of a lung, is a potential complication of respiratory distress syndrome in neonates. However, it would not typically cause symptoms such as increased feeding without weight gain, abdominal distention, and vomiting.
Choice B rationale
Congenital cardiac disease could potentially cause symptoms such as increased feeding without weight gain, but it would not typically cause abdominal distention and vomiting. Furthermore, congenital cardiac disease would likely have been detected prior to the onset of respiratory distress syndrome.
Choice C rationale
Necrotizing enterocolitis is a serious intestinal condition that can occur in premature infants, particularly those with respiratory distress syndrome. Symptoms can include increased feeding without weight gain, abdominal distention, and vomiting.
Choice D rationale
An allergy to infant formula could potentially cause symptoms such as increased feeding without weight gain, abdominal distention, and vomiting. However, this would not typically be associated with respiratory distress syndrome. .
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