A nurse is caring for a client who had a vaginal delivery 2 hr ago. Which of the following actions should the nurse anticipate in the care of this client? (Select all that apply.)
Massage a firm fundus.
Determine whether the fundus is midline.
Document fundal height.
Observe the lochia during palpation of fundus.
Administer methylergonovine maleate if uterus is boggy.
Correct Answer : B,C,D,E
Answer: B, C, D, E
Rationale:
A) Massage a firm fundus: If the fundus is already firm, routine massage is not necessary. Instead, the nurse should monitor the fundus for firmness and position. Massaging is indicated only if the fundus is boggy or atonic to promote uterine contraction.
B) Determine whether the fundus is midline: Checking the position of the fundus is essential to assess for potential complications. A fundus that is not midline could indicate bladder distention, which can interfere with uterine contraction and lead to postpartum hemorrhage.
C) Document fundal height: Documenting the height of the fundus is important for monitoring uterine involution. The fundus should be at the level of the umbilicus 1-2 hours postpartum, and any deviation from expected findings should be noted for ongoing assessment.
D) Observe the lochia during palpation of fundus: Observing lochia during fundal assessment helps identify potential complications such as excessive bleeding or clots. It is crucial for the nurse to monitor lochia in conjunction with fundal assessment to ensure appropriate postpartum recovery.
E) Administer methylergonovine maleate if the uterus is boggy: Methylergonovine is indicated for uterine atony (a boggy uterus) to promote uterine contractions and reduce the risk of postpartum hemorrhage. If the fundus is found to be boggy during assessment, administration of this medication should be anticipated.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
C) A client who has a diagnosis of preeclampsia reports epigastric pain and unresolved headache:
Epigastric pain and unresolved headache are signs of worsening preeclampsia, indicating possible impending eclampsia, a severe complication characterized by seizures. These symptoms suggest a significant deterioration in the client's condition and require immediate medical attention to prevent serious maternal and fetal complications.
A) A client who is at 28 weeks of gestation and receiving terbutaline reports fine tremors:
Fine tremors are a common side effect of terbutaline, which is often used to suppress preterm labor. While tremors can be uncomfortable for the client, they are not typically life-threatening and can often be managed without immediate medical intervention.
B) A client who has a diagnosis of preeclampsia has 2+ proteinuria and 2+ patellar reflexes:
While proteinuria and increased reflexes are indicative of preeclampsia, they are not immediate concerns unless other severe symptoms are present. However, the combination of epigastric pain and unresolved headache in a client with preeclampsia indicates a worsening condition that requires urgent medical attention.
D) A tearful client who is at 32 weeks of gestation and is experiencing irregular, frequent contractions:
While tearfulness and irregular, frequent contractions should be assessed, they are not typically indicators of an immediately life-threatening condition. In this scenario, the client's symptoms of epigastric pain and unresolved headache are more concerning and require immediate reporting to the healthcare provider.
Correct Answer is B
Explanation
B) Assist the client to the bathroom to void:
A slightly boggy and displaced fundus to the right suggests a full bladder. A full bladder can displace the uterus and interfere with uterine contractions, leading to uterine atony. Therefore, the nurse should assist the client to the bathroom to void. Emptying the bladder will help the uterus to contract properly and return to its midline position.
A) Ask the client to rate her pain:
Pain assessment is important for overall client care but is not the priority in this situation. The displacement of the fundus suggests a physiological issue rather than pain being the primary concern.
C) Encourage the client to move to the left lateral position:
While positioning can assist with uterine displacement in some cases, the priority action is to address the full bladder. Once the client has emptied her bladder, the nurse can encourage a left lateral position to help optimize uterine contraction.
D) Encourage the client to perform Kegel exercises:
Kegel exercises are not indicated for addressing a boggy and displaced fundus. These exercises are typically used to strengthen the pelvic floor muscles, which can help with urinary incontinence and promote healing postpartum. However, they will not directly address the issue of a displaced fundus caused by a full bladder.
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