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
Mongolian spots are common, benign skin markings that some newborns have, but they are not related to rubella exposure during pregnancy.
Choice B rationale
Jaundice is a common condition in newborns, characterized by a yellowing of the skin and eyes, usually due to an immature liver. It's not specifically linked to maternal rubella exposure.
Choice C rationale
Transient strabismus, or temporary misalignment of the eyes, can occur in newborns but is unrelated to rubella. It usually resolves on its own as the newborn's muscles develop.
Choice D rationale
Deafness is a significant risk associated with congenital rubella syndrome. Rubella can damage the developing auditory system in utero, leading to permanent hearing loss in the newborn.
Correct Answer is D
Explanation
Choice A rationale
Lecithin/sphingomyelin (L/S) ratio does not indicate genetic disorders; it's used to assess fetal lung maturity.
Choice B rationale
The test does not determine placental function. It specifically evaluates fetal lung maturity through the ratio of lecithin to sphingomyelin in amniotic fluid.
Choice C rationale
The test is not used to assess the risk of Rh incompatibility. The L/S ratio focuses on lung development rather than blood compatibility issues.
Choice D rationale
The L/S ratio assesses the baby's lung maturity, indicating if the lungs produce enough surfactant for proper function after birth.