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
Choice A rationale:
Fever: A hallmark sign of inflammation, fever is a common and often early manifestation of endometritis. The body's
thermostat, located in the hypothalamus, is reset to a higher temperature in response to infection or inflammation. This
triggers a cascade of physiological events, including chills, shivering, and increased heat production, as the body attempts to
fight off pathogens. In endometritis, the fever is typically 100.4°F (38°C) or higher.
Chills: Often accompanying fever, chills are a sensation of coldness despite a normal or elevated body temperature. They result
from involuntary muscle contractions, which generate heat in an attempt to raise the body's temperature. Chills can be mild or
severe, and they often precede a rise in temperature.
Choice B rationale:
Increased heart rate: Tachycardia, or an increased heart rate, can occur in endometritis, but it is not a specific finding. It can be
present in various other conditions, including anxiety, pain, dehydration, anemia, and other infections. While it may be a sign
of endometritis, it's not considered a primary manifestation.
Choice C rationale:
Lower abdominal pain: Lower abdominal pain is a common symptom in postpartum women, but it is not always indicative of
endometritis. It can result from uterine contractions, incisional pain (if a cesarean section was performed), bladder distention,
constipation, or other postpartum complications. While it may be present in endometritis, it's not a specific finding.
Choice D rationale:
Unusual vaginal discharge: Lochia, the normal postpartum vaginal discharge, can vary in color and amount. However, unusual
vaginal discharge, such as foul-smelling or purulent discharge, can be a sign of endometritis. It's important to note that not all
women with endometritis will have abnormal discharge.
Correct Answer is A
Explanation
Choice A rationale:
Umbilical cord compression is a serious condition that can deprive the fetus of oxygen and nutrients. It can occur during labor
due to various factors, such as excessive fetal movement, a long umbilical cord, or decreased amniotic fluid.
Key signs of umbilical cord compression include:
Variable decelerations: These are abrupt decreases in the fetal heart rate (FHR) that vary in duration, depth, and timing. They
are often caused by cord compression, as the compression temporarily reduces blood flow to the fetus.
Late decelerations: These are delayed decreases in the FHR that occur after the peak of a uterine contraction. They can also be
a sign of cord compression, as the compression can impair placental blood flow.
Loss of FHR variability: This refers to a decrease in the normal fluctuations of the FHR. It can be a sign of fetal distress,
including cord compression.
Immediate action is crucial when umbilical cord compression is suspected. The nurse should:
Notify the provider immediately.
Change the mother's position: This can help relieve pressure on the cord. Common positions include:
Lateral positioning (lying on the side)
Trendelenburg position (lying on the back with the head tilted down)
Knee-chest position (kneeling with the chest on the bed)
Administer oxygen to the mother: This can increase fetal oxygenation.
Prepare for possible interventions: These may include amnioinfusion (infusing fluid into the amniotic sac to increase fluid
volume), internal fetal monitoring, or cesarean delivery.
Choice B rationale:
Head compression is a common occurrence during labor as the fetal head descends through the birth canal. It usually does not
require intervention unless it causes significant changes in the FHR or other signs of fetal distress.
Choice C rationale:
Maternal opioid administration can affect the FHR, but it is not typically a cause for immediate concern unless there are
significant changes in the FHR or other signs of fetal distress. The nurse should continue to monitor the FHR closely and report
any concerns to the provider.
Choice D rationale:
Lateral decelerations are not a recognized pattern of fetal heart rate decelerations. The correct term for decelerations that
occur after the peak of a contraction is "late decelerations."
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.