Ati lpn ob maternal newborn
Ati lpn ob maternal newborn ( 28 Questions)
A nurse is collecting data from a client who gave birth 12 hr ago.The nurse notes the fundus is deviated to the right, boggy, and 2 cm above the umbilicus.Which of the following actions should the nurse take first?
Inserting an indwelling urinary catheter may be necessary if the client is unable to void, but it is not the first action.
Administering methylergometrine to the client is not the first action. This medication stimulates uterine contractions and can help reduce postpartum bleeding, but the initial step is to address the full bladder.
Obtaining a stat hemoglobin level is important if there is a concern for significant blood loss, but it is not the first action.
Assisting the client to void is the first action the nurse should take. A full bladder can cause the fundus to deviate to the right and become boggy. Voiding helps the uterus contract and return to its normal position.
Choice D rationale
Assisting the client to void is the first action the nurse should take. A full bladder can cause the fundus to deviate to the right and become boggy. Voiding helps the uterus contract and return to its normal position.
Choice A rationale
Inserting an indwelling urinary catheter may be necessary if the client is unable to void, but it is not the first action.
Choice B rationale
Administering methylergometrine to the client is not the first action. This medication stimulates uterine contractions and can help reduce postpartum bleeding, but the initial step is to address the full bladder.
Choice C rationale
Obtaining a stat hemoglobin level is important if there is a concern for significant blood loss, but it is not the first action.