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 A
Explanation
Choice A rationale
Chorioamnionitis. Based on the information provided, the patient is at risk of developing chorioamnionitis, which is an infection of the membranes surrounding the fetus.
Choice B rationale
Preeclampsia. There is no information provided that would indicate the patient is at risk of developing preeclampsia.
Choice C rationale
Gestational diabetes. There is no information provided that would indicate the patient is at risk of developing gestational diabetes.
Choice D rationale
Preterm labor. There is no information provided that would indicate the patient is at risk of developing preterm labor.
Correct Answer is C
Explanation
Choice A rationale
Monitoring axillary temperature is important for all newborns to prevent hypothermia. However, it is not the priority intervention for a newborn who is small for gestational age (SGA). These newborns are at a higher risk for hypoglycemia due to decreased stores of glycogen and a lower rate of gluconeogenesis.
Choice B rationale
Monitoring weight is important for all infants, and ongoing monitoring is important for infants who are SGA. However, it is not the priority intervention for this client at this time.
Choice C rationale
This is the correct answer. Newborns who are SGA are at a higher risk for hypoglycemia. Therefore, monitoring of blood glucose levels is a priority intervention.
Choice D rationale
Providing age-appropriate stimulation is important for all newborns. However, it is not the priority intervention for a newborn who is SGA2.
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