A nurse is assisting in the care of a client who is 4 hr postpartum. Which of the following interventions should the nurse 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
Correct Answer : A,B
A. Ask the client to empty their bladder – Correct; a full bladder can displace the uterus and prevent it from contracting effectively.
B. Perform fundal massage – Correct; fundal massage helps stimulate uterine contractions and reduce postpartum bleeding.
C. Nothing, this is an expected finding – Incorrect; a boggy uterus is not expected and requires intervention to prevent hemorrhage.
D. Ambulate the client in the hallway – Incorrect; while ambulation is beneficial postpartum, it is not the immediate intervention for a non-firm uterus.
E. Give pain medications – Incorrect; pain medications do not directly address uterine atony or bleeding.
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Related Questions
Correct Answer is C
Explanation
A. Feel for a full bladder. – Incorrect; a full bladder can contribute to postpartum bleeding, but checking fundal firmness should be prioritized first.
B. Request the provider perform a vaginal examination. – Incorrect; the nurse should assess the fundus and attempt interventions first before calling the provider.
C. Check the client’s fundus. – Correct; the priority action is to assess the fundus for firmness, as a boggy uterus is the most common cause of postpartum hemorrhage.
D. Measure the client’s vital signs. – Incorrect; while vital signs are important, assessing fundal tone and initiating interventions come first.
Correct Answer is C
Explanation
A. Avoid the use of aspirin. – Incorrect; aspirin use is not a major risk factor for neural tube defects (NTDs).
B. Avoid consumption of alcohol. – Incorrect; alcohol consumption can cause fetal alcohol syndrome, but it is not directly linked to NTDs.
C. Eat foods fortified with folic acid. – Correct; folic acid is essential for neural tube development, and adequate intake reduces the risk of NTDs, such as spina bifida and anencephaly.
D. Increase intake of iron. – Incorrect; iron is crucial for preventing anemia in pregnancy but does not significantly impact NTD risk.
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