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.
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Related Questions
Correct Answer is B
Explanation
Choice A rationale
Encouraging the client to perform Kegel exercises can help strengthen pelvic floor muscles, but it does not address the immediate problem of a displaced and boggy uterus.
Choice B rationale
Assisting the client to the bathroom to void is the correct action. A full bladder can displace the uterus and prevent it from contracting properly, which can lead to uterine atony and increased risk of postpartum hemorrhage.
Choice C rationale
Asking the client to rate her pain is important, but it does not address the immediate problem of a displaced and boggy uterus.
Choice D rationale
Encouraging the client to move to the left lateral position can improve venous return and cardiac output, but it does not address the immediate problem of a displaced and boggy uterus
Correct Answer is D
Explanation
Choice A rationale
Fetal hyperinsulinemia is a condition where the fetus produces an excess amount of insulin, and it is more commonly associated with macrosomia (large for gestational age) rather than being small for gestational age.
Choice B rationale
Preterm delivery can result in a baby being small for birth weight, but it does not cause a baby to be small for gestational age. Small for gestational age means the baby’s weight is less than the 10th percentile for their gestational age.
Choice C rationale
Perinatal asphyxia, a lack of oxygen before, during, or just after birth, does not cause a baby to be small for gestational age. It can cause other complications, such as organ damage.
Choice D rationale
Placental inefficiency, where the placenta does not work as well as it should, can cause a baby to be small for gestational age. This is because the baby may not receive enough oxygen and nutrients from the mother.
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