A nurse is assisting in the care of a client who had a vaginal birth 2 hours ago. Which of the following actions should the nurse take? (Select all that apply.)
Document fundal height
Observe the lochia during palpation of fundus
Massage a firm fundus
Determine whether the fundus is midline
Administer terbutaline if the fundus is boggy
Correct Answer : A,B,D
Choice A:
Document fundal height. This is a correct action because the nurse should monitor the involution of the uterus by measuring the fundal height and comparing it to the expected level. The fundus should descend about one fingerbreadth (1 cm) per day after delivery and be at the level of the umbilicus immediately after birth.
Choice B:
Observe the lochia during palpation of the fundus. This is a correct action because the nurse should assess the amount, color, and consistency of the lochia (vaginal discharge) during the fundal massage. The lochia should change from rubra (red) to serosa (pink) to alba (white) over time and not increase in amount or revert to a previous stage.
Choice C:
Massage a firm fundus. This is an incorrect action because a firm fundus indicates adequate uterine contraction and involution. Massaging a firm fundus can cause discomfort and bleeding for the client. The nurse should only massage a boggy (soft) fundus to stimulate contraction and prevent hemorrhage.
Choice D:
Determine whether the fundus is midline. This is a correct action because the nurse should check if the fundus is deviated to either side, which may indicate a full bladder. A full bladder can interfere with uterine contraction and cause bleeding or infection. The nurse should assist the client to void if the fundus is not midline.
Choice E:
Administer terbutaline if the fundus is boggy. This is an incorrect action because terbutaline is a tocolytic drug that relaxes the uterine muscle and inhibits contractions. It is used to stop preterm labor, not to treat postpartum hemorrhage. The nurse should administer oxytocin or other uterotonic drugs if the fundus is boggy and does not respond to massage.
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Naxlex Comprehensive Predictor Exams
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Correct Answer is B
Explanation
Choice A reason:
Administering methylergometrine to the client is not the first action the nurse should take. Methylergometrine is a medication that stimulates uterine contractions and can help reduce postpartum bleeding. However, it can also cause hypertension and should be used with caution in clients with high blood pressure. Furthermore, the nurse should first identify and address the cause of the boggy and deviated fundus before giving any medication.
Choice B reason:
Assisting the client to void is the first action the nurse should take. A full bladder can displace the uterus and prevent it from contracting properly, leading to uterine atony and bleeding.
The nurse should help the client empty her bladder by encouraging her to use the bathroom, providing privacy, running water, or using a bedpan. This can help the uterus return to its normal position and tone.
Choice C reason:
Inserting an indwelling urinary catheter is not the first action the nurse should take. A urinary catheter can be used to drain the bladder if the client is unable to void or has a large amount of residual urine. However, it can also increase the risk of infection and trauma to the urethra
and bladder. The nurse should first try noninvasive methods to help the client void, such as those mentioned in choice B.
Choice D reason:
Obtaining a stat hemoglobin level is not the first action the nurse should take. A hemoglobin level can indicate the extent of blood loss and the need for transfusion or other interventions. However, it is not a priority over restoring uterine tone and preventing further bleeding. The nurse should first assist the client to void and then massage the fundus if it remains boggy.
Correct Answer is D
Explanation
Choice A:
Two arteries and two veins. This is incorrect because the umbilical cord normally has only three blood vessels: one vein and two arteries. Having four blood vessels is a rare anomaly that can be associated with congenital defects. •
Choice B:
Two veins and one artery. This is incorrect because the umbilical cord normally has only one vein and two arteries. Having two veins and one artery is another rare anomaly that can also be associated with congenital defects. •
Choice C:
One artery and one vein. This is incorrect because the umbilical cord normally has two arteries and one vein. Having only one artery and one vein is a common anomaly that occurs in about 1% of singleton pregnancies and 5% of twin pregnancies. It can be associated with intrauterine growth restriction, congenital anomalies, and perinatal mortality. •
Choice D:
Two arteries and one vein. This is correct because the umbilical cord normally has two arteries and one vein. The vein carries oxygenated blood from the placenta to the fetus, while the arteries carry deoxygenated blood from the fetus to the placenta. The umbilical cord also contains Wharton's jelly, which is a gelatinous substance that protects the blood vessels from compression.
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