The nurse assesses the client's fundus six hours after birth and shortly after the client voided 400 mL, and finds the fundus to be midline at the umbilicus and boggy. The nurse interprets this as an indication of:
1. A normal involution.
2. Retained urine.
3. Uterine bleeding.
4. Uterine trauma.
3
Rationale: A large, boggy uterus is indicative of uterine bleeding, which can be caused by retained pieces of placenta and must be acted on quickly.
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The nurse is preparing to document that an older patient is experiencing nocturnal myoclonus. What assessment finding is consistent with this documentation?
A) Five leg jerks or movements per hour of sleep B) Any number of leg jerks related to the use of antidepressants C) Five leg jerks brought on by an epileptic seizure during a night's sleep D) Leg jerks in combination with episodes of breathing cessation during sleep
Which of the following would the nurse assess for in a client diagnosed with overconsumption of macronutrients?
A) Diabetes B) GI distress C) Hypoglycemia D) Hypotension
The nurse notes that a patient has an irregularly shaped pupil in the left eye. The nurse will:
A) Ask the patient whether this is normal for him or her. B) Check the patient's pupillary responses again. C) Refer the patient to an ophthalmologist immediately. D) Use a stronger light source to check the anterior chamber.
An assessment finding for a 55-year-old patient that alerts the nurse to the presence of osteoporosis is
a. a measurable loss of height. b. the presence of bowed legs. c. the aversion to dairy products. d. a statement about frequent falls.