A nurse is planning to administer misoprostol 50 mcg intravaginally for cervical ripening to a client who is at 40 weeks of gestation.

Available is misoprostol 200 mcg tablets. How many tablets should the nurse plan to administer?

Choice A rationale

Fundal height measurement is a simple clinical tool used to estimate gestational age and monitor fetal growth. The correct technique involves using a non-stretchable measuring tape to measure the distance in centimeters from the upper border of the symphysis pubis (a fixed bony landmark) to the highest point of the uterine fundus.

Choice B rationale

A full bladder can artificially elevate the uterine fundus, leading to an overestimation of the fundal height and an inaccurate assessment of fetal growth and gestational age. The nurse should instruct the client to empty their bladder before the measurement is taken to ensure the most reliable result.

Choice C rationale

The fundal height measurement is taken vertically, along the midline of the client's abdomen, from the symphysis pubis to the fundus. Measuring horizontally would not provide a clinically relevant or reproducible measure for assessing fetal growth or comparing against expected gestational age measurements.

Choice D rationale

Fundal height measurement should be performed with the client in the supine position with the knees slightly flexed. Placing the client in the left-lateral position is done to prevent supine hypotension syndrome (aorta-caval compression) but would make a standardized and accurate fundal height measurement impossible to obtain.

Choice A rationale

Bladder distention upon palpation indicates urinary retention, meaning the client is unable to void effectively or empty the bladder completely. In the postpartum period, a full bladder can inhibit uterine contraction and increase the risk of postpartum hemorrhage because a distended bladder displaces the uterus, preventing it from clamping down appropriately. The normal range for post-void residual volume is typically less than 100 mL.

Choice B rationale

Not feeling the urge to urinate may be due to decreased bladder sensation following labor and delivery or effects of regional anesthesia, which can lead to urinary retention. Effective voiding is characterized by the ability to sense the urge to void, initiate urination, and empty the bladder, typically passing at least 150 mL per void after catheter removal.

Choice C rationale

Lateral displacement of the uterus is a common sign of a distended bladder. A full bladder pushes the uterus out of its normal midline position, impairing its ability to contract effectively, which increases the risk for uterine atony and subsequent postpartum hemorrhage. The fundus should remain firm and in the midline position after effective voiding.

Choice D rationale

The firming of the fundus with massage indicates that the uterus is contracting, which is essential for preventing postpartum hemorrhage by compressing the blood vessels at the placental site. Effective voiding allows the uterus to remain in its midline position, facilitating proper involution and contractility, which is reflected by a firm fundus.