A nurse is collecting data from a postpartum client and notes the client's fundus is boggy and displaced to the right. Which of the following actions should the nurse take?
Position the client on her left side.
Encourage the client to perform Kegel exercises.
Ask the client to rate her pain.
Assist the client to the bathroom to void.
The Correct Answer is D
Choice A reason: Position the client on her left side is incorrect, as this action is not indicated for a client who has a boggy and displaced fundus. Positioning the client on her left side can enhance uterine blood flow and placental perfusion, but it does not address the cause of uterine atony or bladder distension.
Choice B reason: Encourage the client to perform Kegel exercises is incorrect, as this action is not indicated for a client who has a boggy and displaced fundus. Kegel exercises can strengthen the pelvic floor muscles and prevent urinary incontinence, but they do not affect the uterine tone or position.
Choice C reason: Ask the client to rate her pain is incorrect, as this action is not a priority for a client who has a boggy and displaced fundus. Asking the client to rate her pain can provide information about the need for analgesics, but it does not address the risk of hemorrhage or infection due to uterine atony or bladder distension.
Choice D reason: Assist the client to the bathroom to void is correct, as this action can resolve the problem of a boggy and displaced fundus. A boggy and displaced fundus indicates uterine atony and bladder distension, which can interfere with uterine contraction and involution and increase the risk of hemorrhage and infection. The nurse should assist the client to empty their bladder and then massage the fundus until it becomes firm and midline.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason:
Bloody show from the vagina is incorrect, as this finding is normal and expected in the second stage of labor. Bloody show refers to the passage of mucus and blood from the cervix, which indicates cervical dilation and effacement.
Choice B reason:
Early decelerations in the FHR is incorrect, as this finding is normal and benign in the second stage of labor. Early decelerations are symmetrical decreases in the FHR that mirror the contractions, which indicate fetal head compression and vagal stimulation. The nurse should continue to monitor the FHR and document the findings.
Choice C reason:
Pelvic pressure with contractions is incorrect, as this finding is normal and expected in the second stage of labor. Pelvic pressure indicates that the fetus is descending into the birth canal and that the client is ready to push.
Choice D reason:
Uterine contraction lasting 2 min is correct, as this finding is abnormal and potentially dangerous in any stage of labor. Uterine contraction lasting 2 min can indicate uterine tetany or hyperstimulation, which can cause fetal distress, placental abruption, uterine rupture, or maternal hemorrhage. The nurse should report this finding to the provider immediately and prepare to intervene as ordered.
Correct Answer is B
Explanation
Choice A reason: Inform the client that she can go to the bathroom whenever needed is incorrect, as this action can put the client at risk of injury or complications. The client may experience orthostatic hypotension, dizziness, weakness, or bleeding after a vaginal birth, which can impair their ability to ambulate safely and independently. The nurse should assist the client to the bathroom and monitor their vital signs and lochia.
Choice B reason: This is the correct action. The nurse should assess the client for any residual effects of analgesia, such as dizziness or unsteadiness, which could increase the risk of falls if the client tries to get up.
Choice C reason: Advise the client to remain in bed for the next few hours is incorrect, as this action can increase the risk of bladder distension, infection, or thrombosis. The nurse should encourage and assist the client to ambulate early and frequently after a vaginal birth, as long as there are no contraindications. The nurse should also monitor the client for signs of orthostatic hypotension and provide support as needed.
Choice D reason: While assisting the client is a good approach, it is important to first evaluate her condition to ensure it is safe for her to get out of bed. If she has been assessed and is deemed safe to ambulate, assisting her to the bathroom with support might be appropriate. However, the initial step is to assess her condition.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today