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
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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 is being taught about the use of metformin. Which of the following should be included?

Correct answer: A

Rationale: Corrected Rationale: Metformin should be taken with food to minimize gastrointestinal side effects. Choice A is the correct answer as taking metformin with meals can help reduce the likelihood of experiencing gastrointestinal side effects like diarrhea and nausea, which are common side effects of metformin. Choice B is incorrect because metformin actually helps lower blood sugar levels and does not cause hyperglycemia. Choice C is incorrect as metformin is usually taken twice or even three times a day, not just once daily. Choice D is incorrect because metformin is an oral medication, not an injectable one.

3. A healthcare professional is caring for a client receiving potassium-sparing diuretics. Which of the following should the healthcare professional monitor?

Correct answer: B

Rationale: Corrected Rationale: When a client is receiving potassium-sparing diuretics, the healthcare professional should monitor for hyperkalemia. Potassium-sparing diuretics can cause potassium retention, leading to elevated potassium levels in the blood. Monitoring potassium levels is crucial to prevent hyperkalemia-related complications such as cardiac arrhythmias. Choices A, C, and D are incorrect because potassium-sparing diuretics typically do not cause hypokalemia, hypoglycemia, or hyponatremia.

4. 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.

5. A nurse is caring for a client with a recent diagnosis of myasthenia gravis. Which of the following medications should the nurse expect to administer?

Correct answer: B

Rationale: Pyridostigmine is the drug of choice for treating myasthenia gravis because it enhances communication between nerves and muscles by inhibiting acetylcholinesterase. Methotrexate (choice A) is not indicated for myasthenia gravis but is used in conditions like rheumatoid arthritis. Baclofen (choice C) is a muscle relaxant used for conditions like spasticity. Atropine (choice D) is not typically used in myasthenia gravis as it can worsen muscle weakness.

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