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 a pattern of contractions can be a sign of labor, it is not the definitive sign of true labor. Contractions may also occur in false labor, also known as Braxton Hicks contractions. These contractions do not lead to changes in the cervix.
Choice B rationale
Changes in the cervix, including effacement (thinning) and dilation (opening), are the definitive signs of true labor. During true labor, contractions lead to progressive changes in the cervix, which allow for the baby to be born.
Choice C rationale
Rupture of the membranes, or “water breaking,” can occur in both true labor and false labor. Therefore, it is not the definitive sign of true labor.
Choice D rationale
The station of the presenting part refers to the position of the baby’s head (or other presenting part) in relation to the mother’s pelvis. While the station can change during labor as the baby descends into the pelvis, it is not the definitive sign of true labor.
Correct Answer is A
Explanation
Choice A rationale
If a client reports feeling down and sad, having no energy, and wanting to cry, the nurse’s priority action should be to ask the client if she has considered harming her newborn. This is because these symptoms may indicate postpartum depression, a serious condition that can lead to harm to both the mother and the baby if left untreated.
Choice B rationale
While reinforcing postpartum and newborn care discharge teaching is important, it is not the priority action in this situation. The client’s emotional health needs to be addressed first.
Choice C rationale
Assisting the family to identify prior use of positive coping skills in family crises can be helpful, but it is not the priority action in this situation. The client’s immediate emotional health needs to be addressed first.
Choice D rationale
Anticipating a prescription by the provider for an antidepressant may be part of the treatment plan for this client, but it is not the priority action. The nurse first needs to assess the safety of the client and her newborn.
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