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 D
Explanation
Choice A rationale
The American Cancer Society does not recommend starting mammograms at age 30 for women at average risk. This age is too young for the initiation of routine screening mammograms.
Choice B rationale
The American Cancer Society does not recommend starting mammograms at age 35 for women at average risk. This age is still considered too young for the initiation of routine screening mammograms.
Choice C rationale
The American Cancer Society does not recommend starting mammograms at age 40 for women at average risk, although women between 40 and 44 have the option to start screening with a mammogram every year.
Choice D rationale
According to the American Cancer Society, women at average risk should start having mammograms at age 45. From age 45 to 54, they should get mammograms every year.
Correct Answer is B
Explanation
Choice A rationale
Giving an infant with a positive PKU test a high protein diet is not recommended. This is because phenylalanine, which cannot be broken down by individuals with PKU, is found in high-protein foods.
Choice B rationale
Parents of infants with a positive PKU test should provide the infant with a diet containing small amounts of phenylalanine. This is because while phenylalanine is harmful in large amounts to individuals with PKU, it is still an essential amino acid that the body needs in small amounts.
Choice C rationale
Early introduction of cow’s milk is not necessary before 1 year of age for infants with a positive PKU test. In fact, cow’s milk is high in phenylalanine and should be avoided.
Choice D rationale
Following up with a pediatric cardiologist is not specifically related to the dietary management of PKU. While regular medical supervision is important for children with PKU, it does not necessarily have to be with a cardiologist.
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