Following delivery, the nurse's assessment reveals a soft, boggy uterus located above the level of the umbilicus. The appropriate intervention is:
Massage the fundus
Initiate measures that encourage voiding
Position the patient flat
Notify the doctor
The Correct Answer is A
Massage the fundus. This is because massaging the fundus (the upper part of the uterus) can help the uterus contract and prevent excessive bleeding after delivery. A soft, boggy uterus indicates uterine atony, which is a failure of the uterus to contract sufficiently after childbirth.
Uterine atony is the most common cause of postpartum hemorrhage, which can be life-threatening if not treated promptly¹².
Choice B is not correct because initiating measures that encourage voiding is not the appropriate intervention for a soft, boggy uterus. A full bladder can interfere with uterine contractions and cause bleeding, so it is important to empty the bladder after delivery. However, this should be done after massaging the fundus.
Choice C is not correct because positioning the patient flat is not the appropriate intervention for a soft, boggy uterus. Positioning the patient flat can increase blood loss and reduce venous return. The patient should be positioned with the head slightly elevated and the legs flexed to improve blood circulation and prevent shock³.
Choice D is not correct because notifying the doctor is not the first intervention for a soft, boggy uterus. Notifying the doctor is important if bleeding persists or worsens despite massaging the fundus. The doctor may order medications or other treatments to stop the bleeding and prevent complications¹.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Fever. This is because fever is a sign of infection, which is a common and potentially serious postpartum complication. Infection can affect various parts of the body, such as the uterus (endometritis), the bladder (cystitis), the breast (mastitis), the wound (wound infection), or the blood (sepsis). Infection can cause symptoms such as fever, chills, pain, foul-smelling discharge, redness, swelling, or warmth at the site of infection.
Choice A is not correct because the change in lochia from red to white is not a sign of postpartum complication. Lochia is the vaginal discharge that occurs after childbirth. It changes color and amount over time, from red to pink to brown to yellow to white. This is a normal process of healing and does not indicate a problem unless the lochia is foul-smelling, heavy, or contains large clots³.
Choice B is not correct because fatigue and irritability are not signs of postpartum complications. Fatigue and irritability are common feelings after childbirth due to hormonal changes, sleep deprivation, physical recovery, and emotional adjustment. They do not necessarily indicate a problem unless they are severe or persistent and interfere with daily functioning or bonding with the baby.
Choice D is not correct because contractions are not signs of postpartum complication. Contractions are normal after childbirth and help the uterus shrink back to its pre-pregnancy size. They are usually mild and subside within a few days. They may be more intense during breastfeeding due to the release of oxytocin, which stimulates uterine contractions.
Correct Answer is A
Explanation
This is because cephalhematoma is a collection of blood under the scalp that does not cross the suture line. It is caused by trauma to the head during delivery, such as from vacuum extraction or forceps. It usually appears within a few hours or days after birth and resolves within weeks or months.


Choice B is not correct because nevus flammeus is a type of birthmark that is also known as port-wine stain. It is a flat, red, or purple patch of skin that can appear anywhere on the body, but often on the face. It is caused by abnormal blood vessels in the skin and does not go away over time³.
Choice C is not correct because the molding is the temporary change in the shape of the head due to pressure during delivery. It does not cause swelling or bruising and usually resolves within a few days.
Choice D is not correct because caput succedaneum is a type of swelling that affects the scalp and crosses the suture line. It is caused by fluid accumulation under the scalp due to pressure during delivery. It usually appears at birth and goes away within a few days.
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