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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?

A.

Insert a urinary catheter.

B.

Massage the fundus.

C.

Have the client urinate.

D.

Administer an analgesic

Answer and Explanation

The Correct Answer is C

A firm, displaced fundus to the right of midline indicates a full bladder. A distended bladder can prevent the uterus from contracting properly and can lead to uterine atony, increasing the risk of postpartum hemorrhage. Therefore, the priority action is to have the client empty her bladder.
This can often be achieved by encouraging the client to urinate or by assisting her with toileting if necessary. Palpating a fundus that is firm and displaced does not indicate the need for fundal massage, as the fundus is already firm. Inserting a urinary catheter may be necessary if the client is unable to void spontaneously, but this should be done after attempting to have the client
 
urinate voluntarily. Administering an analgesic is not indicated based on the information provided.
 


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Related Questions

Correct Answer is ["B","D","F"]

Explanation

Correct Choices for Indicating Understanding:

  • "I should make sure that my baby feeds 8 to 12 times per day."
  • "My baby's stools should turn to a yellow color within the next day or two."
  • "I should expect my breasts to become harder, warmer, and more tender when my milk comes in."

Rationale

  • "Because of my baby's weight loss, I need to supplement with formula after breastfeeding."

    • This statement does not necessarily indicate an understanding of discharge teaching, as supplementation should only be done based on medical advice and not solely based on perceived weight loss.

  • "I should make sure that my baby feeds 8 to 12 times per day."

    • This statement indicates an understanding of discharge teaching, as frequent feeding is important for newborns to ensure adequate nutrition and hydration, and to promote milk production in breastfeeding mothers.

  • "I should cover my sore nipples with plastic-lined breast pads after every feeding."

    • This statement does not indicate proper understanding, as plastic-lined breast pads can retain moisture and increase the risk of infection. Instead, breathable pads or natural remedies are often recommended.

  • "My baby's stools should turn to a yellow color within the next day or two."

    • This statement indicates an understanding of normal neonatal stool changes, as breastfed babies' stools typically transition to a yellow color within a few days of birth.

  • "I can increase my milk supply by drinking more water."

    • While staying hydrated is important, this statement alone is insufficient for indicating a comprehensive understanding of increasing milk supply. Effective breastfeeding practices and frequent nursing are more directly impactful.

  • "I should expect my breasts to become harder, warmer, and more tender when my milk comes in."

    • This statement indicates an understanding of the common experience of breast engorgement when milk comes in, which is a normal part of the breastfeeding process.

Correct Answer is D

Explanation

A. Fundus is at level of the umbilicus is well contracted and therefore, not of concern.

B. A saturated perineal pad in 15 min or less can indicate excessive bleeding.
C. Approximated edges of episiotomy indicate proper wound repair and therefore, not of concern.
D. Deep Tendon reflexes 4+-4+ are hyperactive and indicate the client is at greatest risk for preeclampsia and seizures; this is the priority.

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