a postpartum clients fundus is firm 3 cm above the umbilicus and displaced to the right which of the following interventions should the nurse take
Logo

Nursing Elites

ATI LPN

PN ATI Capstone Maternal Newborn

1. 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?

Correct answer: C

Rationale: The correct intervention for a postpartum client with a firm, displaced fundus is to assist the client to void then reassess the fundus. Displacement of the uterus to the right is often a sign of bladder distention, which can prevent the uterus from contracting properly and increase the risk of postpartum hemorrhage. By helping the client to void, the nurse can alleviate the bladder distention, allowing the uterus to contract effectively. Massaging the fundus (Choice A) may not address the underlying issue of bladder distention. Administering oxytocin (Choice B) is not indicated without assessing and addressing the cause of the displacement. Notifying the healthcare provider (Choice D) is premature before implementing initial nursing interventions to address the potential cause of the displaced fundus.

2. A client has been prescribed metformin. What should be included in the teaching?

Correct answer: B

Rationale: The correct answer is to take metformin with food. This is important to minimize gastrointestinal side effects and improve absorption. Choice A is incorrect as metformin is not typically associated with weight gain. Choice C is wrong as metformin is not an insulin but a medication that helps control blood sugar levels. Choice D is also incorrect as metformin is not known to cause hyperglycemia.

3. A nurse is assessing a client who has systemic lupus erythematosus (SLE). Which of the following findings should the nurse expect?

Correct answer: A

Rationale: The correct answer is A: Butterfly rash on the face. A butterfly-shaped rash across the nose and cheeks is a classic symptom of systemic lupus erythematosus (SLE), an autoimmune disease. Weight gain (Choice B) is not typically associated with SLE. Joint deformities (Choice C) are more commonly seen in conditions like rheumatoid arthritis. Increased hair growth (Choice D) is not a typical finding in SLE.

4. A nurse is providing teaching to a client who is at 34 weeks of gestation and is scheduled for a nonstress test. Which of the following statements should the nurse plan to make?

Correct answer: B

Rationale: The correct statement for the nurse to make is choice B, 'You should expect the test to take about 30 minutes.' The nonstress test is used to assess fetal well-being by monitoring fetal heart rate in response to movements. Choice A is incorrect because medications are not typically administered during a nonstress test. Choice C is incorrect as there is no need for the client to fast before the test. Choice D is incorrect because determining fetal lung maturity is usually done through other tests, not the nonstress test.

5. A nurse is caring for a client who is experiencing preterm labor and has a new prescription for terbutaline. Which of the following findings is a contraindication for the administration of this medication?

Correct answer: A

Rationale: The correct answer is A, heart disease. Terbutaline is contraindicated in clients with heart disease because it can lead to tachycardia and other cardiac complications due to its beta-agonist properties. Choice B, cervical dilation of 2 cm, is not a contraindication for terbutaline administration in preterm labor. Choice C, gestational age of 34 weeks, does not contraindicate the use of terbutaline for preterm labor. Choice D, allergy to penicillin, is not related to the contraindications of terbutaline.

Similar Questions

A nurse is caring for a client with celiac disease. Which food should be removed from the meal tray?
A nurse is caring for a client who is receiving oxytocin to augment labor. The nurse notes recurrent variable decelerations of the FHR. Which of the following actions should the nurse take first?
A client with preeclampsia is receiving magnesium sulfate intravenously. What action should the nurse take if the client develops toxicity?
A client with heart failure who presents with dyspnea, bibasilar crackles, and frothy sputum should receive which dietary recommendation?
A client newly diagnosed with nephrotic syndrome is being taught by a nurse. Which statement indicates that the client understands the teaching?

Access More Features

ATI LPN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

ATI LPN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

Other Courses