A nurse is caring for a patient who experienced a vaginal birth 3 hours ago.
Upon palpation, the fundus is displaced to the right of the midline, is firm, and is two fingerbreadths above the umbilicus.
What actions should the nurse complete at this time?
Insert a urinary catheter.
Massage the fundus.
Have the patient urinate.
Administer an analgesic.
The Correct Answer is C
Choice A rationale
Inserting a urinary catheter is not typically the first action when the fundus is displaced. It is more commonly done when the bladder is distended and the patient is unable to urinate.
Choice B rationale
Massaging the fundus is usually done when the uterus is soft or boggy to help it contract and prevent postpartum hemorrhage. However, in this case, the fundus is firm, indicating that the uterus is well contracted.
Choice C rationale
Having the patient urinate is the appropriate action when the fundus is displaced to the right of the midline. This displacement often indicates a full bladder, which can push the uterus to the side. After the patient urinates, the uterus often returns to the midline position.
Choice D rationale
Administering an analgesic is not the first action when the fundus is displaced. Pain medication is typically given for postpartum discomfort or afterbirth pains, not for a displaced fundus.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
While it’s true that a newborn’s stools will transition in color, it typically takes a few days longer than one or two. Initially, the stools are a greenish-black color known as meconium. Over the next few days, as the baby begins digesting breast milk or formula, the stools will gradually transition to a yellow color.
Choice B rationale
This statement is correct. After childbirth, the breasts undergo a process known as engorgement when they start to produce milk. This can cause the breasts to become harder, warmer, and more tender. This is a normal part of the postpartum period and is a sign that the body is preparing to feed the baby.
Choice C rationale
While it’s true that abdominal discomfort generally decreases over time after childbirth, it’s important to note that the rate of decrease can vary greatly among individuals. Factors such as the type of delivery (vaginal or cesarean), individual pain tolerance, and the presence of any complications can all influence the rate of decrease in abdominal discomfort.
Choice D rationale
While it’s true that many women do feel more energetic as their bodies recover from childbirth, this is not always the case. Factors such as sleep deprivation, hormonal changes, and the physical demands of caring for a newborn can all contribute to feelings of fatigue and exhaustion. Therefore, while some women may feel more energetic, others may continue to feel tired for several weeks or even months after giving birth.
Correct Answer is D
Explanation
Choice A rationale
Applying cold compresses 20 minutes before each feeding may not be the most effective way to manage breast engorgement. Cold compresses can help to reduce swelling and relieve pain, but they do not address the underlying cause of engorgement, which is the accumulation of milk in the breasts.
Choice B rationale
Drinking herbal tea to reduce engorgement is not a proven method. While some herbs are believed to have galactagogue properties (increase milk production), they do not directly address breast engorgement. Furthermore, the safety and efficacy of many herbal remedies are not well-studied, and some may have side effects.
Choice C rationale
Letting the baby drain one breast at each feeding can help to alleviate engorgement, but it may not be sufficient if the feedings are spaced too far apart. The breasts continue to produce milk between feedings, and if the milk is not removed, engorgement can occur.
Choice D rationale
Feeding the baby every 2 hours can help to manage breast engorgement. Regular feedings help to ensure that the milk is being removed from the breasts, preventing the buildup that leads to engorgement.
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