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?

Correct Answer: C

Rationale: Correct Answer: C - Have the client urinate. Rationale: 1. Displacement to the right of midline indicates a full bladder pushing the fundus. 2. A full bladder can prevent the fundus from contracting properly. 3. Having the client urinate will help the bladder empty, allowing the fundus to contract effectively and prevent complications like postpartum hemorrhage. Summary of Incorrect Choices: A: Massaging the fundus is not necessary as it is already firm. B: Inserting a urinary catheter is invasive and should be avoided unless necessary. D: Administering an analgesic is not indicated for fundus displacement; addressing the full bladder is the priority.

Correct Answer: B

Rationale: The correct answer is B because phototherapy works by breaking down unconjugated bilirubin in the skin to a water-soluble form, allowing it to be excreted from the body. This process does not activate the liver (choice A), nor does it activate Vitamin K (choice C) or dissolve the bilirubin for excretion from the skin (choice D). Phototherapy specifically targets the unconjugated bilirubin in the skin, converting it to a form that can be eliminated through the urine and stool.

Correct Answer: C

Rationale: The correct answer is C because lethargy, poor perfusion, and apnea are classic signs of neonatal sepsis. Lethargy indicates decreased activity and responsiveness, poor perfusion suggests inadequate blood circulation, and apnea is a serious respiratory issue. These signs indicate a systemic infection affecting multiple organs. Choices A, B, and D do not align with typical symptoms of neonatal sepsis. Tachypnea, poor feeding, and temperature instability (Choice A) are more general and can be seen in various conditions. Increased alertness, reduced crying, and stable vitals (Choice B) are not indicative of sepsis, as sepsis typically causes the opposite. Hyperthermia, bradycardia, and cyanosis (Choice D) can be present in sepsis, but they are not as specific or as common as the signs in Choice C.

Correct Answer: D

Rationale: The correct answer is D. Using a peanut ball widens the pelvis, which can help rotate the baby into an optimal position for birth. This position can aid in reducing the likelihood of prolonged labor and the need for interventions. Encouraging side-lying position (A) may not provide the necessary pelvic widening. Placing the mother in lithotomy position (B) can impede the baby's descent. Encouraging ambulation (C) may not specifically address the occiput posterior position and may not provide enough pelvic opening.

Correct Answer: A

Rationale: The correct answer is A: Feed the newborn formula immediately. The first action for a newborn showing signs of hypoglycemia is to provide them with a source of glucose to raise their blood sugar levels quickly. Formula feeding is an effective way to achieve this as it provides a concentrated source of glucose. Encouraging breastfeeding or formula feeding (choice B) is a good option but may not address the immediate need for glucose. Monitoring glucose levels every hour (choice C) is important but not the first action to take in an acute situation. Notifying the healthcare provider immediately (choice D) is necessary but should come after addressing the immediate need for glucose.