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.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is B
Explanation
Choice A rationale
Disabling the driver-side airbags is not advisable as airbags provide crucial protection in the event of a collision. Proper seating position is a safer alternative.
Choice B rationale
Moving the seat as far away as possible from the steering wheel reduces the risk of injury from airbag deployment and allows ample space for the growing abdomen, providing better safety for both mother and baby.
Choice C rationale
Wearing the lap belt high across the abdomen is incorrect and dangerous as it can cause injury to the fetus. The belt should be low across the hips.
Choice D rationale
Placing the shoulder harness across the gravid uterus is incorrect. The harness should go between the breasts and to the side of the belly, not across it, to avoid compression injuries in the event of a crash.
Correct Answer is ["A","C","E"]
Explanation
Choice A rationale:
Breech presentation is a contraindication for dinoprostone as it increases the risk of complications during labor and delivery. Using dinoprostone to induce labor in a non-vertex presentation can lead to issues such as cord prolapse or obstructed labor, which necessitate a cesarean section for safe delivery.
Choice B rationale:
Terbutaline administration is used to manage preterm labor by relaxing the uterus. While it is relevant in labor management, it does not directly contraindicate the use of dinoprostone. Terbutaline and dinoprostone can be used in conjunction if properly managed.
Choice C rationale:
Fetal heart rate (FHR) monitoring showing abnormalities is a potential reason to withhold dinoprostone. Dinoprostone can increase uterine contractions, potentially stressing the fetus. A stable FHR with moderate variability indicates fetal well-being; however, if there were concerns, the provider might withhold dinoprostone.
Choice D rationale:
A WBC count of 9,500/mm³ is within the normal range and does not indicate an infection or condition that would contraindicate dinoprostone use. Elevated WBC count could raise concerns, but in this case, it is normal and not a contraindication.
Choice E rationale:
Lesions noted on the vaginal introitus and labia majora, likely caused by Herpes simplex virus, are a contraindication for dinoprostone. Active genital herpes lesions increase the risk of neonatal herpes transmission, making vaginal delivery risky. In such cases, cesarean delivery is often preferred to prevent transmission.