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 rationale
Age of 25 years is not typically identified as a potential risk factor for infertility. Women in their mid-twenties are often in their peak reproductive years.
Choice B rationale
A history of smoking can potentially impact fertility. Smoking can harm the ovaries and the eggs they produce, potentially leading to fertility issues.
Choice C rationale
Diabetes since the age of 15 could potentially impact fertility. Diabetes can cause irregular menstrual cycles and other reproductive issues, which could lead to difficulty conceiving. Choice D rationale
Weight below the standard for height and age could potentially impact fertility. Being underweight can lead to irregular menstrual cycles and ovulation, which could lead to difficulty conceiving.
Correct Answer is B
Explanation
Choice A rationale
Smoking has been associated with an increased risk of developing endometriosis. It is thought that certain substances found in tobacco smoke may have a role in the development or progression of endometriosis14.
Choice B rationale
Regular exercise has been associated with a decreased risk of endometriosis. Physical activity may influence the body’s production of estrogen, a hormone that is thought to play a role in endometriosis14.
Choice C rationale
A higher body mass index (BMI) has been associated with a decreased risk of endometriosis. It is thought that body fat may influence the levels of hormones such as estrogen in the body14.
Choice D rationale
Age is a risk factor for endometriosis, with the condition being more common in women in their 30s and 40s. However, endometriosis can occur in any woman who has menstrual periods14.
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