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.)
Administer methylergonovine maleate if the uterus is boggy
Massage a firm fundus.
Document fundal height.
Observe the lochia during palpation of the fundus
Determine whether the fundus is midline.
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 B
Explanation
Rationale:
A. While restricting visits from young children may help reduce infection risk, it is not a sufficient or specific intervention for neutropenic precautions.
B. Avoiding raw fruits is critical because they can harbor bacteria and increase the risk of infection in neutropenic clients. Cooked fruits are safer options.
C. Measuring temperature should occur more frequently than every 8 hours, ideally every 4 hours or more, to quickly identify fever, a sign of infection.
D. Disposable gloves should be used from within the client's room to maintain strict infection control measures; using gloves from outside could introduce contaminants.
Correct Answer is B
Explanation
Rationale:
A. Taking the medication 2 hours apart from calcium supplements is important, but the timing is not the primary instruction; the focus should be on the medication itself.
B. Levothyroxine should be taken on an empty stomach, ideally 30 to 60 minutes before breakfast, to enhance absorption.
C. Taking a double dose if a dose is missed can lead to toxicity; patients should be instructed to skip the missed dose and resume the regular schedule.
D. While taking the medication with a small sip of water is acceptable, it is not the most critical instruction for ensuring proper absorption and effectiveness of levothyroxine.