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 C
Explanation
Choice A rationale
Wearing gloves while gardening is a recommended practice after a mastectomy, especially on the side where lymph nodes have been removed. This is to protect the skin and reduce the risk of infection, which could trigger lymphedema.
Choice B rationale
It is indeed recommended that blood pressures be taken in the unaffected arm after a mastectomy. This is because the pressure from the cuff can obstruct lymph flow and potentially trigger lymphedema in the arm where lymph nodes have been removed. Choice C rationale
Wearing clothing with elastic sleeves is not recommended after a mastectomy. Elastic bands can restrict lymph flow and increase the risk of lymphedema.
Choice D rationale
Similar to blood pressure measurements, it is recommended that blood specimens be drawn from the unaffected arm after a mastectomy. This is to avoid injury to the lymphatic system in the arm where lymph nodes have been removed, which could trigger lymphedema.
Correct Answer is B
Explanation
Choice A rationale
Lying down with arms at the side is not the recommended position for a breast self-exam. The recommended positions are either standing or lying down with the arm raised.
Choice B rationale
Using the finger pads of the three middle fingers to apply pressure to the breast is a correct technique for a breast self-exam. This method allows for thorough examination of the breast tissue.
Choice C rationale
It is not correct to avoid checking under the arm if the breast feels fine. The breast tissue extends into the underarm area, so it is important to check this area as well during a breast self-exam.
Choice D rationale
Working from left to right down the breast towards the ribs is not a standard instruction for a breast self-exam. The recommended method is to use a circular, up-and-down, or wedge pattern.
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