A nurse is performing an assessment on a postpartum patient.
The uterus is found to be displaced to the right.
Which of the following actions should the nurse take?
Action A.
Action B.
Action C.
Action D.
The Correct Answer is B
Choice A rationale:
Placing the mother in Trendelenburg's position would not correct the uterine displacement. Trendelenburg's position involves
lowering the head of the bed and raising the feet, which can actually worsen uterine displacement by increasing pressure on
the uterus from the abdominal organs.
It is not indicated for uterine displacement and could potentially have adverse effects on the patient's hemodynamic status
and respiratory function.
Choice C rationale:
Notifying the physician is important, but it is not the first action the nurse should take.
The nurse should assess the patient and attempt to correct the displacement before notifying the physician.
Choice D rationale:
Recording the findings is important for documentation, but it is not an intervention that will correct the uterine displacement.
Choice B rationale:
Massaging the fundus is the correct action to take when a postpartum uterus is displaced.
The fundus is the top of the uterus, and massaging it can help to stimulate the uterine muscles to contract and return to their
normal position.
This is often effective in correcting mild to moderate uterine displacements.
Here are the steps involved in massaging the fundus:
Locate the fundus: The nurse should first locate the fundus by palpating the abdomen just below the umbilicus.
Apply gentle pressure: Once the fundus is located, the nurse should apply gentle pressure with the fingertips in a circular
motion.
Continue massaging: The massage should be continued for several minutes, or until the uterus is felt to be firm and in the
midline position.
Additional notes:
If the uterine displacement is severe, or if the patient is experiencing pain or bleeding, the nurse should notify the physician
immediately.
Other interventions that may be used to correct uterine displacement include:
Assisting the patient to empty her bladder
Straight catheterization
Administration of oxytocin to stimulate uterine contractions
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is Choice A
Choice A rationale: Uterine atony is the leading cause of postpartum hemorrhage. Assessing fundal tone identifies if the uterus is boggy and requires massage to stimulate contraction and reduce bleeding.
Choice B rationale: Vaginal examination may identify trauma or retained tissue, but it is not the first-line assessment. Initial nursing action focuses on uterine tone before escalating to provider intervention.
Choice C rationale: Vital signs help detect hypovolemia or shock but do not address the bleeding source. Fundal assessment precedes vitals to determine if bleeding is due to uterine atony.
Choice D rationale: A full bladder can displace the uterus and worsen bleeding, but this is assessed after fundal tone. Fundus check is prioritized to identify and treat uterine atony immediately.
Correct Answer is A
Explanation
Choice A rationale:
Significance of retraction: Retraction of the fetal head against the maternal perineum is a crucial sign that the fetal shoulders
are about to be delivered. It indicates that the fetal head has fully descended into the pelvic outlet and is ready to rotate and
deliver the shoulders.
Urgency of preparation: It's essential for the nurse to promptly prepare for the delivery of the shoulders to ensure a safe and
timely birth:
Gather necessary equipment, including sterile gloves, towels, and possibly a suction bulb.
Position the mother appropriately, often in a semi-sitting or lithotomy position, to facilitate delivery.
Support the perineum to reduce tearing and guide the delivery of the shoulders.
Communicate with the mother to encourage effective pushing and maintain clear instructions throughout the process.
Anticipate potential complications, such as shoulder dystocia, and be prepared to assist with maneuvers to resolve it if
necessary.
Choice B rationale:
Rest during second stage: While rest is important during labor, encouraging rest between contractions at this specific point
(retraction of the head) could delay the delivery of the shoulders, potentially increasing risks for both mother and baby.
Maintaining momentum: The second stage of labor typically involves active pushing and uterine contractions to facilitate
delivery. Resting at this stage could interrupt the natural progression of labor.
Choice C rationale:
Role of blood pressure monitoring: Monitoring blood pressure is essential throughout labor to detect potential complications
like preeclampsia or hemorrhage. However, in this specific scenario, where the fetal head is already retracted and the
shoulders are imminent, preparing for delivery takes priority over routine blood pressure checks.
Choice D rationale:
Oxygen administration: Oxygen is sometimes administered during labor to support the mother's and baby's oxygen levels.
However, it's not a standard intervention for all laboring women, and its necessity would be based on individual assessments
and clinical judgment. In the absence of specific indications for oxygen, such as maternal distress or fetal heart rate concerns,
it's not the priority action when the fetal head is retracted and delivery of the shoulders is impending.
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