A nurse in a hospital is caring for a client who is 4 hour postpartum. Which of the following interventions should the nurse first perform after finding that the client's uterus is not firm? (Select All that Apply.)

Ask the client to empty their bladder

Perform fundal massage

Nothing, this is an expected finding

Ambulate the client in the hallway

Give pain medications

Answer and Explanation

Correct Answer : A,B

A) Ask the client to empty their bladder:
One of the first actions the nurse should take when the uterus is not firm (often referred to as uterine atony) is to ask the client to empty their bladder. A full bladder can interfere with uterine contraction and cause the uterus to be boggy or soft, which can lead to postpartum hemorrhage. Encouraging the client to void may help the uterus contract more effectively and reduce the risk of complications.

B) Perform fundal massage:
If the uterus is not firm, performing a fundal massage is essential. Fundal massage helps stimulate uterine contractions and helps the uterus contract to its normal size, reducing the risk of bleeding. It is a critical intervention in postpartum care to ensure that the uterus remains firm and does not become atonic, which can cause excessive blood loss.

C) Nothing, this is an expected finding:
A soft uterus (uterine atony) is not an expected finding 4 hours postpartum. A firm uterus is expected at this point to prevent hemorrhage. The nurse should take immediate action to address the issue of uterine atony, as failure to do so can lead to significant postpartum hemorrhage, a life-threatening complication.

D) Ambulate the client in the hallway:
Ambulation may be helpful later in the postpartum period to encourage circulation and prevent thromboembolism, but it is not a priority when the uterus is not firm. The first priority is to address uterine atony, and actions like emptying the bladder and massaging the fundus should be performed before ambulating the client.

E) Give pain medications:
While pain management is important, it is not the priority intervention when the uterus is not firm. The nurse must first address the cause of uterine atony (such as bladder distention) and stimulate uterine contractions via fundal massage to ensure that the uterus is firm and the client is not at risk for excessive bleeding. Pain medications can be given once the immediate uterine concerns have been addressed.

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Correct Answer is B

Explanation

A) Uterine contractions:
While uterine contractions cause significant pain and discomfort during labor, particularly in the first and early second stages, by the time the client reaches the second stage of labor, the cervix is fully dilated, and the main cause of pain and pressure is no longer from the contractions themselves. Instead, the pain and pressure described in the second stage are primarily due to the fetal head descending through the birth canal, applying pressure to the perineum.

B) The fetal head applying pressure:
The pain and pressure reported in the second stage of labor are primarily due to the fetal head descending into and through the birth canal, putting pressure on the cervix, vagina, perineum, and pelvic floor. This pressure is a major source of discomfort in the second stage, as the fetal head stretches the tissues of the perineum, which is essential for facilitating birth. The sensation of pressure on the pelvic floor is often described by clients during this stage.

C) Nerve stimulation:
Nerve stimulation occurs during labor as a result of uterine contractions and the fetal descent, which can cause radiating pain to the lower back, thighs, and pelvic region. However, the specific pain and pressure in the pelvis and perineum described by the client are more directly related to the fetal head applying pressure, rather than generalized nerve stimulation. Nerve stimulation may contribute to pain but is not the primary cause of the pelvic and perineal pressure at this stage.

D) Cervical dilation:
Cervical dilation occurs in the earlier stages of labor (latent and active phases), and while it contributes to pain during these stages, by the second stage, the cervix should be fully dilated (10 cm). The pain and pressure that the client is feeling in the second stage are less about cervical dilation and more about the descent of the fetal head through the birth canal and its pressure on the perineum and pelvic floor.

A. Uterus firm and midline B. Moderate amount of lochia rubra C. Uterus boggy and midline D. Moderate amount of lochia rubra E. foul odor present F. Temperature 37.5° C (99.5° F) G. Heart rate 88/min H. Temperature 38.3° C (100.9° F) I. Heart rate 105/min

Correct Answer is ["C","E","H","I"]

Explanation

Findings that require follow-up:

Uterus boggy at 24 hr postpartum:

A boggy uterus indicates poor uterine contraction, which can lead to postpartum hemorrhage. Effective uterine contraction is crucial to prevent excessive bleeding after delivery, and this finding warrants immediate intervention, such as fundal massage or administering uterotonic medications.

Lochia rubra with foul odor:

Foul-smelling lochia is a sign of potential infection, often indicative of endometritis, which is an infection of the uterine lining. The presence of this odor requires prompt follow-up and possibly antibiotic treatment to prevent further complications.

Elevated temperature (38.3°C/100.9°F) at 24 hr postpartum:

A postpartum fever may indicate infection, such as endometritis or a urinary tract infection (UTI). This fever should be investigated further to determine the cause and appropriate treatment, as untreated infections can lead to serious complications.

Increased heart rate (105/min) at 24 hr postpartum:

Tachycardia in the postpartum period can be a sign of infection or early signs of hemodynamic instability, possibly due to blood loss or infection. Close monitoring is necessary, and the healthcare provider should be notified to evaluate the cause and initiate treatment if necessary.

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A nurse in a hospital is caring for a client who is 4 hour postpartum. Which of the following interventions should the nurse first perform after finding that the client's uterus is not firm? (Select All that Apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client in the second stage of labor reports to a nurse that they are feeling pain and pressure in their pelvis and perinium. Which of the following should the nurse understand that this pain is caused by?

Correct Answer is B

Explanation

Correct Answer is ["C","E","H","I"]

Explanation

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