A nurse is preparing to perform a fundal massage for a postpartum client who is experiencing uterine atony. In which order should the nurse plan to perform the following actions?
Ask the client to lie on her back and with her knees flexed.
Position one hand around the top of the client's fundus and one hand just above the client's symphysis pubis.
Rotate the upper hand to massage the client's uterus while using slight downward pressure to compress the fundus.
Observe the client's perineum for the passage of clots and the amount of bleeding.
The Correct Answer is A, B, C, D
The correct answer is A, B, C, D.
The nurse should plan to perform the following actions in this order:
A. Ask the client to lie on her back and with her knees flexed.
B. Position one hand around the top of the client’s fundus and one hand just above the client’s symphysis pubis.
C. Rotate the upper hand to massage the client’s uterus while using slight downward pressure to compress the fundus.
D. Observe the client’s perineum for the passage of clots and the amount of
bleeding.
Fundal massage is performed to stimulate uterine contractions and prevent
postpartum hemorrhage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The nurse should report a fundal height of 38 cm to the provider.
Fundal height is measured from the top of the pubic bone to the top of the uterus and is used to assess fetal growth.
A fundal height measurement that is larger than expected for gestational age may indicate macrosomia, which is a common complication of gestational diabetes mellitus.
Choice A is incorrect because non-pitting pedal edema is common during late pregnancy and is usually caused by physiologic edema resulting from hormone- induced sodium retention.
Choice C is incorrect because 12 fetal movements in an hour are within normal
range.
Choice D is incorrect because a fasting blood glucose level of 90 mg/dL is within normal range for a pregnant woman with gestational diabetes mellitus.
Correct Answer is B
Explanation
A client who is 80% effaced and 8 cm dilated is in active labor and at risk for postpartum hemorrhage.
Choice A is not an answer because ectopic pregnancy occurs when a fertilized egg implants outside of the uterus and is not a risk for a client who is in active labor.
Choice C is not an answer because an incompetent cervix refers to a cervix that dilates prematurely during pregnancy and is not a risk for a client who is in active labor.
Choice D is not an answer because hyperemesis gravidarum refers to severe nausea and vomiting during pregnancy and is not a risk for a client who is in active labor.
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