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 D
Explanation
A. Tilting the client onto her right side with her legs elevated does not directly address the underlying cause of postpartum hemorrhage.
B. Oxytocin is a uterotonic medication commonly used to help control and prevent PPH by promoting uterine contractions, which can help to compress blood vessels and reduce bleeding. However, it is not the priority action.
C. Inserting an indwelling urinary catheter may be necessary to monitor urine output and empty the bladder but is not a priority.
D. Massaging the client's fundus to promote contractions is a standard intervention and initial action for managing PPH
Correct Answer is D
Explanation
If the mother is Rh-negative and the fetus is Rh-positive, the mother may produce anti-Rh antibodies, which can cross the placenta and cause hemolysis of the fetal red blood cells, leading to hyperbilirubinemia in the newborn.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
