Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A postpartum client's fundus is firm, 3 cm above the umbilicus, and displaced to the right. Which of the following interventions should the nurse take?
A. Assist the client to void then reassess the fundus.
Assisting the client to void is a priority intervention in this situation. A full bladder can displace the uterus and prevent it from contracting effectively, leading to a boggy and high- positioned fundus. After the client empties her bladder, the nurse should reassess the fundus to ensure it has descended to its appropriate location, which is usually at or just below the level of the umbilicus.
B. Document the findings as within normal limits.
Documenting the findings as within normal limits is incorrect because a firm, displaced fundus that is 3 cm above the umbilicus is not considered normal. This finding indicates that the uterus is not contracting adequately, and the nurse should take appropriate actions to address the issue.
C. Gently massage the client's fundus.
Gently massaging the client's fundus is not the correct intervention in this case. Massaging a firm fundus could cause uterine irritation and should be avoided. Instead, the nurse should encourage the client to empty her bladder, which often helps the uterus contract and descend to its proper position.
D. Encourage the client to ambulate.
Encouraging the client to ambulate may be helpful in some cases to promote uterine contractions and involution. However, in this situation, the priority is to address the full bladder, as it is a common cause of a displaced and high fundus shortly after delivery.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Maternal Newborn Proctored Exam. Take the full exam now
Full Explanation
Choice A rationale:
Assisting the client to void is a priority intervention in this situation. A full bladder can displace the uterus and prevent it from contracting effectively, leading to a boggy and high- positioned fundus. After the client empties her bladder, the nurse should reassess the fundus to ensure it has descended to its appropriate location, which is usually at or just below the level of the umbilicus.
Choice B rationale:
Documenting the findings as within normal limits is incorrect because a firm, displaced fundus that is 3 cm above the umbilicus is not considered normal. This finding indicates that the uterus is not contracting adequately, and the nurse should take appropriate actions to address the issue.
Choice C rationale:
Gently massaging the client's fundus is not the correct intervention in this case. Massaging a firm fundus could cause uterine irritation and should be avoided. Instead, the nurse should encourage the client to empty her bladder, which often helps the uterus contract and descend to its proper position.
Choice D rationale:
Encouraging the client to ambulate may be helpful in some cases to promote uterine contractions and involution. However, in this situation, the priority is to address the full bladder, as it is a common cause of a displaced and high fundus shortly after delivery.
Similar Questions
A laboring client received meperidine IV one hour prior to delivery. Which of the following medications should the nurse have available to counteract the effects of this medication on the newborn?
A. Fentanyl.
Fentanyl is an opioid analgesic and is not used to counteract the effects of meperidine in the newborn. Both fentanyl and meperidine are opioids, and using fentanyl in this context would not counteract the effects of meperidine.
B. Flumazenil.
Flumazenil is a medication used to reverse the effects of benzodiazepines, not opioids like meperidine. It is not appropriate for countering the effects of meperidine in the newborn.
C. Naloxone.
Naloxone is an opioid antagonist that can reverse the effects of opioids like meperidine. When a newborn has been exposed to opioids during labor, such as meperidine given to the mother, there is a risk of respiratory depression in the newborn. Naloxone can quickly reverse this effect and restore normal respiratory function.
D. Benztropine.
Benztropine is an anticholinergic medication used to treat side effects of antipsychotic drugs and is not relevant in this situation. It would not counteract the effects of meperidine on the newborn.
Full Explanation
Choice A rationale:
Fentanyl is an opioid analgesic and is not used to counteract the effects of meperidine in the newborn. Both fentanyl and meperidine are opioids, and using fentanyl in this context would not counteract the effects of meperidine.
Choice B rationale:
Flumazenil is a medication used to reverse the effects of benzodiazepines, not opioids like meperidine. It is not appropriate for countering the effects of meperidine in the newborn.
Choice C rationale:
Naloxone is an opioid antagonist that can reverse the effects of opioids like meperidine. When a newborn has been exposed to opioids during labor, such as meperidine given to the mother, there is a risk of respiratory depression in the newborn. Naloxone can quickly reverse this effect and restore normal respiratory function.
Choice D rationale:
Benztropine is an anticholinergic medication used to treat side effects of antipsychotic drugs and is not relevant in this situation. It would not counteract the effects of meperidine on the newborn.
A nurse is caring for a client who has just delivered her first newborn. The nurse anticipates hyperbilirubinemia due to Rh incompatibility. The nurse should understand that hyperbilirubinemia occurs with Rh incompatibility for which of the following reasons?
A. The client's blood does not contain the Rh factor, so she produces anti-Rh antibodies that cross the placental barrier and cause hemolysis of red blood cells in newborns.
Rh incompatibility occurs when an Rh-negative client is exposed to Rh-positive fetal blood, typically during a prior pregnancy or delivery. The client’s immune system produces anti-Rh antibodies that cross the placenta in subsequent pregnancies, attacking the Rh-positive red blood cells of the fetus. This hemolysis releases bilirubin, leading to hyperbilirubinemia in the newborn.
B. The client's blood contains the Rh factor, and the newborn's does not, and antibodies that destroy red blood cells are formed in the fetus.
Rh incompatibility only occurs when the client is Rh-negative and the fetus is Rh-positive. An Rh-positive client will not form antibodies against an Rh-negative fetus, as their immune system recognizes the Rh factor as normal.
C. The client has a history of receiving a transfusion with Rh-negative blood.
This choice is not related to the mechanism of Rh incompatibility. Receiving a transfusion with Rh-negative blood would not cause the mother's immune system to produce anti-Rh antibodies or lead to Rh incompatibility with her newborn.
D. The client's anti-A and anti-B antibodies cross the placenta and cause the destruction of the fetal red blood cells.
This choice describes the ABO blood group system, not the Rh factor. ABO incompatibility can occur when a mother with blood type O (producing anti-A and anti-B antibodies) has a newborn with blood type A, B, or AB, leading to hemolysis of the fetal red blood cells. However, the question specifically mentions Rh incompatibility, which involves the Rh factor, not the ABO system.
Full Explanation
Choice A rationale:
Rh incompatibility occurs when an Rh-negative client is exposed to Rh-positive fetal blood, typically during a prior pregnancy or delivery. The client’s immune system produces anti-Rh antibodies that cross the placenta in subsequent pregnancies, attacking the Rh-positive red blood cells of the fetus. This hemolysis releases bilirubin, leading to hyperbilirubinemia in the newborn.
Choice B rationale:
Rh incompatibility only occurs when the client is Rh-negative and the fetus is Rh-positive. An Rh-positive client will not form antibodies against an Rh-negative fetus, as their immune system recognizes the Rh factor as normal.
Choice C rationale:
This choice is not related to the mechanism of Rh incompatibility. Receiving a transfusion with Rh-negative blood would not cause the mother's immune system to produce anti-Rh antibodies or lead to Rh incompatibility with her newborn.
Choice D rationale:
This choice describes the ABO blood group system, not the Rh factor. ABO incompatibility can occur when a mother with blood type O (producing anti-A and anti-B antibodies) has a newborn with blood type A, B, or AB, leading to hemolysis of the fetal red blood cells. However, the question specifically mentions Rh incompatibility, which involves the Rh factor, not the ABO system.
A nurse is teaching the parent of a newborn about bottle feeding. Which of the following statements by the parent indicates a need for further instruction?
A. "I will keep my baby's head elevated while he is feeding.”
The parent's statement in choice A, "I will keep my baby's head elevated while he is feeding,” indicates an understanding of proper bottle feeding techniques. Keeping the baby's head slightly elevated can help prevent choking and aspiration during feedings. This is a correct statement, and no further instruction is needed in this regard.
B. "I will allow my baby to burp several times during each feeding.”
The parent's statement in choice B, "I will allow my baby to burp several times during each feeding,” also demonstrates knowledge of appropriate bottle feeding practices. Burping the baby during and after feedings helps release swallowed air, reducing the likelihood of excessive gas and discomfort. This statement is correct, and no additional instruction is required.
C. "I will tip the nipple so air is present as my baby sucks.”
Choice C is the incorrect statement because tipping the nipple to introduce air while the baby sucks is not a recommended practice. In fact, it can lead to an increased intake of air, potentially causing gas, discomfort, and colic in the baby. Therefore, further instruction is needed to correct this misconception.
D. "My baby will have soft, formed yellow stools.”
Choice D is not directly related to the need for further instruction in bottle feeding techniques and is not addressed in the explanation.
Full Explanation
The correct answer is choice C: "I will tip the nipple so air is present as my baby sucks.”
Choice A rationale:
The parent's statement in choice A, "I will keep my baby's head elevated while he is feeding,” indicates an understanding of proper bottle feeding techniques. Keeping the baby's head slightly elevated can help prevent choking and aspiration during feedings. This is a correct statement, and no further instruction is needed in this regard.
Choice B rationale:
The parent's statement in choice B, "I will allow my baby to burp several times during each feeding,” also demonstrates knowledge of appropriate bottle feeding practices. Burping the baby during and after feedings helps release swallowed air, reducing the likelihood of excessive gas and discomfort. This statement is correct, and no additional instruction is required.
Choice C rationale:
Choice C is the incorrect statement because tipping the nipple to introduce air while the baby sucks is not a recommended practice. In fact, it can lead to an increased intake of air, potentially causing gas, discomfort, and colic in the baby. Therefore, further instruction is needed to correct this misconception.
Choice D Rationale:
Choice D is not directly related to the need for further instruction in bottle feeding techniques and is not addressed in the explanation.