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?
Insert a urinary catheter.
Massage the fundus.
Have the client urinate.
Administer an analgesic
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The likely cause of postpartum hypotension is PPH. Assessing the client should be the first step before initiating management.
B. Oxytocin infusion is used to prevent or manage uterine atony and postpartum hemorrhage.
Assessment should be done before administration of oxytocin.
C. Obtaining a type and crossmatch is important if there is established hemorrhage. Should follow assessment
D. Initiating oxygen therapy by nonrebreather mask should be done after established hypoxemia on assessment of vital signs
Correct Answer is ["B","E"]
Explanation
Post maturity refers to a pregnancy that extends beyond 42 weeks of gestation. Newborns who are postmature may exhibit certain characteristics due to the prolonged time spent in the uterus.
These include cracked, peeling skin, abundant vernix, overgrown nails, increased scalp hair, decreased subcutaneous fat and deep creases on the palms and soles.
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