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 A
Explanation
Choice A is correct. The square window angle, formed by the intersection of the ear and the jawline, is an important physical assessment finding in neonates. In full-term babies, this angle is typically greater than 90 degrees, appearing more rounded. However, in preterm babies, the angle is often closer to 90 degrees, appearing more square due to underdeveloped facial features and subcutaneous tissue.
Choice B is incorrect. While leathery and cracked skin can be present in both term and preterm babies, it's not a specific indicator of prematurity alone. It can be caused by various factors like intrauterine growth restriction, dehydration, or underlying skin conditions.
Choice C is incorrect. The popliteal angle, formed by flexing the knee and measuring the angle between the thigh and lower leg, is not a reliable indicator of prematurity. It can vary even among term babies and is influenced by other factors like muscle tone and positioning.
Choice D is incorrect. Pronounced plantar creases, the lines on the soles of the feet, are also not specific to prematurity. While they may be deeper in some preterm babies, they can also be present in full-term infants and their depth can vary greatly between individuals.
Correct Answer is ["B","D","E"]
Explanation
Choice A rationale
The cervical cap is a barrier method of contraception, not a hormonal method. It is a small, thimble-shaped cup made of silicone that is inserted into the vagina before sex to prevent pregnancy.
Choice B rationale
Depo Provera is a hormonal method of contraception. It is an injection of the hormone progestin that is given every three months to prevent pregnancy.
Choice C rationale
The diaphragm is a barrier method of contraception, not a hormonal method. It is a shallow, dome-shaped cup with a flexible rim that is inserted into the vagina before sex to cover the cervix and prevent pregnancy.
Choice D rationale
The intrauterine device (IUD) can be a hormonal method of contraception. Hormonal IUDs release progestin into the uterus to prevent pregnancy.
Choice E rationale
The vaginal ring is a hormonal method of contraception. It is a small, flexible ring that is inserted into the vagina. It releases estrogen and progestin to prevent pregnancy
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