Question

A nurse is caring for a client who is 2 hr postpartum following a vaginal birth. Which of the following findings indicates the client's bladder is distended?

Answer 1

Correct Answers:

Fundus palpable to right of midline

Rationale :

🔷 A fundus that is displaced to the right of midline in a postpartum client suggests a distended bladder, which pushes the uterus out of its normal position.

🔷 This interferes with uterine contraction and increases the risk of postpartum hemorrhage.

🔷 Other signs of bladder distention may include fundal elevation above the umbilicus and reduced urinary output.

🔷 The priority intervention is to assist the client to void or perform a bladder scan if necessary.

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Answer 2

Correct Answers:

Cephalohematoma

Rationale :

🔶 A cephalohematoma is a collection of blood between the skull bone and periosteum that does not cross suture lines.

🔶 It is typically caused by birth trauma, especially in assisted deliveries (e.g., vacuum or forceps).

🔶 It may take weeks to resolve and increases the risk for hyperbilirubinemia due to breakdown of trapped red blood cells.

🔶 This finding should be documented and monitored, but it typically resolves on its own without intervention.

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Answer 3

Correct Answers:

It prevents the formation of Rh antibodies in mothers who are Rh negative.

Rationale :

💠 Rh(D) immunoglobulin (RhoGAM) is administered to Rh-negative mothers to prevent sensitization to Rh-positive fetal red blood cells.

💠 It works by neutralizing fetal Rh antigens before the mother’s immune system can produce antibodies.

💠 This prevents complications like hemolytic disease of the newborn in future pregnancies.

💠 It is given at 28 weeks and within 72 hours postpartum if the baby is Rh-positive.

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Answer 4

Correct Answers:

"You should place your nipple and some of the areola into her mouth."

Rationale :

💎 For effective breastfeeding, the newborn must latch onto the nipple and part of the areola, not just the nipple alone.

💎 This promotes better suction, prevents nipple trauma, and ensures efficient milk transfer.

💎 A shallow latch can cause cracked nipples, pain, and poor weight gain in the newborn.

💎 Teaching proper latching technique is a key nursing role during initial postpartum care.

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Answer 5

Correct Answers:

a sudden gush of clear fluid from the vagina

Rationale :

⬛ A sudden gush of clear fluid is a classic sign of rupture of membranes, which may indicate the onset of labor.

⬛ This can be spontaneous or occur with contractions and typically warrants evaluation for labor progression and fetal well-being.

⬛ It is important to assess the color, odor, and time of rupture to rule out infection or meconium-stained fluid.

⬛ Other options like right-sided pain or headache are not early signs of labor.

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Answer 6

Correct Answers:

Right lower

Rationale :

🔷 During Leopold maneuvers, if the nurse palpates a round, firm, movable part (the fetal head) in the fundus, the fetus is in a breech position.

🔷 If the long smooth surface (the fetal back) is on the client’s right side, the fetal heart tones (FHTs) are best auscultated in the right lower quadrant.

🔷 FHTs are typically heard below the umbilicus in cephalic presentation and above the umbilicus in breech.

🔷 Positioning assists the nurse in placing the Doppler in the most effective location to detect the heart rate.

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Answer 7

Correct Answers:

Respiratory distress

Rationale :

🔶 The priority assessment following a cesarean delivery is checking for respiratory distress, as newborns delivered via cesarean may retain lung fluid.

🔶 Cesarean babies are not exposed to the thoracic compression of the birth canal, which normally helps expel fluid from the lungs.

🔶 Signs of distress include nasal flaring, grunting, retractions, or tachypnea.

🔶 While lacerations or acrocyanosis may occur, airway patency and adequate oxygenation take precedence.

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Answer 8

Correct Answers:

Change the client's position.

Rationale :

💠 Late decelerations indicate uteroplacental insufficiency, and the first step is to improve uterine perfusion by repositioning the client, usually to the left side.

💠 This reduces vena cava compression and enhances blood flow to the placenta.

💠 Other steps like oxygen administration or IV fluid increase may follow, but position change is the most immediate and least invasive action.

💠 For example, turning the client to her left lateral side can often resolve the late deceleration pattern quickly.

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Answer 9

Correct Answers:

Blood pressure 80/56 mm Hg<br»

Rationale :

💎 A drop in blood pressure after epidural analgesia is a common but potentially dangerous side effect and must be addressed immediately.

💎 This hypotension can compromise placental perfusion, affecting fetal oxygenation and maternal stability.

💎 It takes priority over pruritus, fever, or weakness, which are expected or less emergent effects.

💎 The nurse should anticipate giving IV fluids, repositioning the client, and possibly notifying the provider.

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Answer 10

Correct Answers:

Have the client urinate.

Rationale :

⬛ A fundus that is elevated and shifted to the right is often caused by a distended bladder, which displaces the uterus.

⬛ Voiding helps reposition the uterus midline and allows it to contract properly, reducing the risk of postpartum hemorrhage.

⬛ While fundal massage is indicated for a boggy uterus, this fundus is described as firm but displaced, pointing to urinary retention.

⬛ Prompt bladder emptying is a first-line, non-invasive intervention.

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QLexNursing

1 :
A nurse is caring for a client who is 2 hr postpartum following a vaginal birth. Which of the following findings indicates the client's bladder is distended?

2 :
The nurse is performing a newborn assessment and evaluates a collection of blood beneath the newborn's scalp that does not cross the suture lines. The nurse documents this finding as

3 :
A nurse is teaching a client who is postpartum and has a new prescription for an injection of Rh(D) immunoglobulin. Which of the following should be included in the teaching?

4 :
A nurse is assisting a client who is postpartum with her first breastfeeding experience. When the client asks how much of the nipple she should put into the newborn's mouth, which of the following responses should the nurse make?

5 :
At the midpoint during pregnancy, you review beginning signs of labor with a client. One of the beginning signs of labor you would review is

6 :
A nurse in a prenatal clinic is caring for a client. Using Leopold maneuvers, the nurse palpates a round, firm, moveable part in the fundus of the uterus and a long, smooth surface on the client's right side. In which abdominal quadrant should the nurse expect to auscultate fetal heart tones?

7 :
A nurse is assessing a newborn immediately following a scheduled cesarean delivery. Which of the following assessments is the nurse's priority?

8 :
A nurse is caring for a client who is in active labor and notes late decelerations in the FHR. Which of the following actions should the nurse take first?

9 :
A nurse is caring for a client who is receiving opioid epidural analgesia during labor. Which of the following findings is the nurse's priority?

10 :
A nurse is caring for a client who experienced a vaginal birth 3 hr ago. Upon palpation, the fundus is displaced to the right of midline, is firm, and is two fingerbreadths above the umbilicus. Which of the following actions should the nurse complete at this time?

QLexNursing

1 : A nurse is caring for a client who is 2 hr postpartum following a vaginal birth. Which of the following findings indicates the client's bladder is distended?

2 : The nurse is performing a newborn assessment and evaluates a collection of blood beneath the newborn's scalp that does not cross the suture lines. The nurse documents this finding as

3 : A nurse is teaching a client who is postpartum and has a new prescription for an injection of Rh(D) immunoglobulin. Which of the following should be included in the teaching?

4 : A nurse is assisting a client who is postpartum with her first breastfeeding experience. When the client asks how much of the nipple she should put into the newborn's mouth, which of the following responses should the nurse make?

5 : At the midpoint during pregnancy, you review beginning signs of labor with a client. One of the beginning signs of labor you would review is

6 : A nurse in a prenatal clinic is caring for a client. Using Leopold maneuvers, the nurse palpates a round, firm, moveable part in the fundus of the uterus and a long, smooth surface on the client's right side. In which abdominal quadrant should the nurse expect to auscultate fetal heart tones?

7 : A nurse is assessing a newborn immediately following a scheduled cesarean delivery. Which of the following assessments is the nurse's priority?

8 : A nurse is caring for a client who is in active labor and notes late decelerations in the FHR. Which of the following actions should the nurse take first?

9 : A nurse is caring for a client who is receiving opioid epidural analgesia during labor. Which of the following findings is the nurse's priority?

10 : A nurse is caring for a client who experienced a vaginal birth 3 hr ago. Upon palpation, the fundus is displaced to the right of midline, is firm, and is two fingerbreadths above the umbilicus. Which of the following actions should the nurse complete at this time?

1 :
A nurse is caring for a client who is 2 hr postpartum following a vaginal birth. Which of the following findings indicates the client's bladder is distended?

2 :
The nurse is performing a newborn assessment and evaluates a collection of blood beneath the newborn's scalp that does not cross the suture lines. The nurse documents this finding as

3 :
A nurse is teaching a client who is postpartum and has a new prescription for an injection of Rh(D) immunoglobulin. Which of the following should be included in the teaching?

4 :
A nurse is assisting a client who is postpartum with her first breastfeeding experience. When the client asks how much of the nipple she should put into the newborn's mouth, which of the following responses should the nurse make?

5 :
At the midpoint during pregnancy, you review beginning signs of labor with a client. One of the beginning signs of labor you would review is

6 :
A nurse in a prenatal clinic is caring for a client. Using Leopold maneuvers, the nurse palpates a round, firm, moveable part in the fundus of the uterus and a long, smooth surface on the client's right side. In which abdominal quadrant should the nurse expect to auscultate fetal heart tones?

7 :
A nurse is assessing a newborn immediately following a scheduled cesarean delivery. Which of the following assessments is the nurse's priority?

8 :
A nurse is caring for a client who is in active labor and notes late decelerations in the FHR. Which of the following actions should the nurse take first?

9 :
A nurse is caring for a client who is receiving opioid epidural analgesia during labor. Which of the following findings is the nurse's priority?

10 :
A nurse is caring for a client who experienced a vaginal birth 3 hr ago. Upon palpation, the fundus is displaced to the right of midline, is firm, and is two fingerbreadths above the umbilicus. Which of the following actions should the nurse complete at this time?