A nurse is caring for a client who had a vaginal delivery 1 day ago. The nurse determines that the client's fundus is firm, located 2 fingerbreadths above the umbilicus, and deviated to the left. Which of the following actions should the nurse take first?
Monitor perineal pads for clots.
Assist the client to empty her bladder.
Notify the provider.
Administer a prescribed analgesic.
The Correct Answer is B
Choice A rationale
"Monitor perineal pads for clots.”. This is incorrect because while monitoring for clots is important, it does not address the underlying issue causing the fundal deviation.
Choice B rationale
"Assist the client to empty her bladder.”. This is correct because a full bladder can cause the uterus to deviate and impede uterine involution. Emptying the bladder helps the uterus to contract properly and return to its normal position.
Choice C rationale
"Notify the provider.”. This is incorrect because the immediate action should be to address the potential cause of the deviation (a full bladder), which can be managed by the nurse.
Choice D rationale
"Administer a prescribed analgesic.”. This is incorrect because administering pain relief does not address the cause of the fundal deviation and does not alleviate the potential issue.
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Correct Answer is D
Explanation
Choice A rationale
A maternal age of 30 years is not a significant risk factor for preeclampsia. Preeclampsia is more common in very young mothers or those over the age of 35.
Choice B rationale
A prepregnancy BMI of 19 is within the normal range and is not considered a risk factor for preeclampsia, which is more commonly associated with higher BMI or obesity.
Choice C rationale
Being in the third pregnancy (multiparity) is not a strong risk factor for preeclampsia. The risk factors are more closely related to the individual's health conditions and first pregnancies.
Choice D rationale
Chronic hypertension is a well-known risk factor for preeclampsia as it indicates pre-existing cardiovascular issues that can predispose one to developing preeclampsia during preg
Correct Answer is A
Explanation
Choice A rationale
Respiratory rate of 10/min is a critical adverse effect, indicating potential respiratory depression due to magnesium sulfate, a serious and life-threatening condition requiring immediate intervention.
Choice B rationale
Urine output of 160 mL in 4 hours is lower than expected but not immediately life-threatening. It needs monitoring but is not as critical as respiratory rate.
Choice C rationale
Diaphoresis, or excessive sweating, can be a side effect of magnesium sulfate but is not life-threatening. It warrants attention but does not require immediate reporting.
Choice D rationale
Nausea is a common, less severe side effect of magnesium sulfate that does not indicate an urgent situation.