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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. A fundus palpable to the right of midline may indicate a distended bladder pushing the uterus to the side, and it requires intervention to promote bladder emptying.
B. Less than 2.5 cm of rubra lochia on a perineal pad is a normal finding in the early postpartum period.
C. Increased thirst is not directly indicative of bladder distention.
D. Frequent uterine contractions are expected in the postpartum period and do not necessarily indicate bladder distention.
Correct Answer is A
Explanation
A. Assessing for respiratory distress is the priority as the newborn's ability to breathe independently is crucial immediately after birth.
B. Acrocyanosis is a common and expected finding in newborns, especially in the first few hours after birth.
C. Accidental lacerations, while important to assess, are not as immediately critical as respiratory distress.
D. While hypothermia is a concern, addressing respiratory distress takes precedence in the immediate postoperative period.
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