A nurse is caring for a client who is postpartum and finds the fundus slightly boggy and displaced to the right. Based on these findings, which of the following actions should the nurse take?
Encourage the client to perform Kegel exercises.
Encourage the client to move to the left lateral position.
Ask the client to rate her pain.
Encourage the client to empty bladder by voiding
The Correct Answer is D
A. Kegel exercises are not indicated for addressing a boggy uterus; emptying the bladder is a more appropriate intervention.
B. Moving to the left lateral position may help, but the primary concern is a full bladder contributing to uterine displacement.
C. Pain assessment is important but does not directly address the issue of a boggy uterus and displacement.
D. Encouraging the client to empty the bladder by voiding is essential, as a full bladder can displace the uterus and contribute to uterine atony.
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Related Questions
Correct Answer is C
Explanation
A. Uterine tetany and overproduction of oxytocin are not typically associated with subinvolution.
B. Multiple gestation and postpartum hemorrhage may contribute to uterine atony but not necessarily subinvolution.
C. The most common causes of subinvolution are retained placental fragments and infection.
D. Postpartum hemorrhage may contribute to uterine atony but is not a direct cause of subinvolution.
Correct Answer is B
Explanation
A. This is not appropriate for the taking-in stage, as the woman may not be ready to absorb new information or focus on self-care. She may need more verbal instruction and demonstration from the nurse.
B. The taking-in stage is a period of passive, dependent behavior in which the woman reviews her childbirth experience and adjusts to the new role of motherhood. She may need to talk about her labor and delivery repeatedly and seek reassurance from others. The nurse should listen attentively and validate her feelings.
C. This is more suitable for the taking-hold stage, which occurs after the taking-in stage. In this stage, the woman becomes more active and independent, and shows interest in learning how to care for herself and her baby.
D. This is also more appropriate for the taking-hold stage, when the woman develops confidence and competence in her maternal role. In the taking-in stage, she may be more focused on her own needs and rely on others to care for the baby.
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