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A nurse is caring for a client who had a vaginal delivery 2 hours ago. Which of the following actions should the nurse anticipate in the care of this client? (Select all that apply.)

A.

Administer methylergonovine maleate if the uterus is boggy

B.

Massage a firm fundus.

C.

Document fundal height.

D.

Observe the lochia during palpation of the fundus

E.

Determine whether the fundus is midline.

Question Solution

Correct Answer : A,C,D,E

Rationale: 

 

A. Administering methylergonovine maleate is indicated if the uterus is boggy (atonic), as it helps to contract the uterus and reduce the risk of postpartum hemorrhage. 

 

B. Massaging a firm fundus is not appropriate; instead, the nurse should massage a boggy (soft) fundus to promote uterine contraction. 

 

C. Documenting fundal height is a necessary action to assess uterine involution and ensure it is progressing as expected after delivery. 

 

D. Observing the lochia during palpation of the fundus is important to assess for any abnormal findings, such as heavy bleeding, which could indicate complications. 

E. Determining whether the fundus is midline is crucial; a displaced fundus may indicate bladder distention, which can affect uterine contraction.


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Correct Answer is A

Explanation

Rationale:

A. Initiating the process to review the medical record is appropriate; clients have the right to access their medical information under HIPAA regulations, and the nurse can assist in starting that process.

B. While there are restricted parts of a medical record, the response lacks a proactive approach to assisting the client in accessing the information they have the right to view.

C. This response is dismissive of the client's request and does not provide an avenue for understanding the medical record better.

D. Although the provider can provide more detailed information about treatment, it does not address the client's right to review their own medical record.

Correct Answer is C

Explanation

Rationale:

A. Withholding the next dose of warfarin may not be necessary at this point, as the INR is elevated but not critically high. Monitoring is essential, but vitamin K administration is indicated if the INR exceeds therapeutic levels significantly.

B. Withholding the heparin infusion is not appropriate since the aPTT is critically elevated, indicating that the client is at risk for bleeding. Heparin should be adjusted, but not entirely withheld without further evaluation.

C. Preparing to administer vitamin K is appropriate because the INR is elevated (1.8), indicating an increased risk for bleeding. Vitamin K is used to reverse the effects of warfarin.

D. Preparing to administer alteplase (a thrombolytic) is unnecessary and inappropriate in this situation, as the client is already receiving anticoagulation therapy with heparin and warfarin.

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