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 C
Explanation
Choice A rationale
Starting each feeding with the same breast can lead to engorgement and decreased milk supply in the other breast.
Choice B rationale
Exclusive breastfeeding is recommended for the first six months. Providing a formula supplement can interfere with milk supply and breastfeeding success.
Choice C rationale
Allowing the newborn to empty the first breast ensures they receive hindmilk, which is richer in fat and essential for growth.
Choice D rationale
Newborns do not need additional water as breast milk or formula provides all necessary hydration.
Correct Answer is C
Explanation
Choice A rationale
Taking an over-the-counter antacid is not recommended for managing nausea during pregnancy without consulting a healthcare provider. Some antacids contain ingredients that may not be safe during pregnancy.
Choice B rationale
Increasing intake of fresh fruits might help with hydration and nutrition but is not specifically effective in managing morning nausea. Some fruits might even exacerbate nausea due to their acidity.
Choice C rationale
Eating dry, bland foods in the morning can help manage nausea for pregnant clients. Foods like crackers, toast, and cereals are easy on the stomach and can help reduce morning sickness.
Choice D rationale
Restricting fluids to 1,000 mL/day is not advisable. Proper hydration is crucial during pregnancy, and such restriction can lead to dehydration and other complications. Fluids should be encouraged rather than restricted.