A nurse is caring for a client who had a vaginal delivery 2 hours ago.
Which of the following actions should the nurse anticipate in the care of this client? (Select all that apply.)
Observe the lochia during palpation of the fundus.
Massage a firm fundus.
Determine whether the fundus is midline.
Document fundal height.
Administer methylergonovine maleate.
Correct Answer : A,C,E
Step 1: The nurse should observe the lochia during palpation of the fundus. This can help assess the amount and type of vaginal discharge after childbirth.
Step 2: The nurse should not massage a firm fundus. If the uterus is firm, it means it is contracting well to control bleeding.
Step 3: The nurse should determine whether the fundus is midline. A uterus that is not midline may indicate a full bladder, which can interfere with uterine contraction and lead to increased bleeding.
Step 4: Documenting fundal height is not typically done postpartum. Instead, the nurse assesses whether the fundus is firm and midline.
Step 5: The nurse should administer methylergonovine maleate if the uterus is boggy. This medication helps the uterus contract to control bleeding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
While excessive fatigue and headache can occur in pregnancy, they are not typically signs of labor.
Choice B rationale
A sudden gush of clear fluid from the vagina, also known as rupture of membranes, is a sign that labor may be starting.
Choice C rationale
Sharp, right-sided abdominal pain is not a typical sign of labor. It could indicate other issues such as appendicitis.
Choice D rationale
An increased pulse rate and upper abdominal pain are not typical signs of labor.
Correct Answer is A
Explanation
The nurse should first assess the fundus of the uterus. If the uterus is not firm (boggy), it may not be contracting well enough to compress the blood vessels and stop the bleeding. The nurse should massage the fundus until it is firm.
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