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.
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Related Questions
Correct Answer is D
Explanation
Cullen's sign is a clinical sign characterized by superficial edema and bruising in the subcutaneous fatty tissue around the umbilicus. It is indicative of intra-abdominal bleeding, such as from a ruptured ectopic pregnancy. Blood in the peritoneum can track along fascial planes to the umbilical area, resulting in discoloration and swelling.
Correct Answer is A
Explanation
A Panting helps the client manage the urge to push and prevents premature pushing, which can cause cervical swelling or injury. This technique helps delay pushing until full dilation is achieved, ensuring a safer delivery process.
B. Helping the client into a comfortable position can facilitate labor progress. However, it may not be the most urgent action given the potential imminent delivery.
C. Voiding is a common suggestion during labor, but if the client feels the urge to push, it may be an indication that the baby is descending and delivery is imminent.
D. The client's urge to push indicates that the baby is descending, and birth is imminent. It would not be safe to have the client walk to the bathroom at this stage, as she may deliver the baby during the process, increasing the risk of an unattended birth.
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