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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Hemorrhage. This is because postpartum hemorrhage (PPH) is severe bleeding and loss of blood after childbirth that can lead to death. The most common cause of PPH is the uterus not contracting properly after delivery. The nurse needs to monitor the client’s pulse and blood pressure frequently to detect signs of shock and blood loss.
Choice A is wrong because thromboembolism is a blood clot that blocks a blood vessel, not a complication of bleeding.
Choice B is wrong because cervical laceration is a tear in the cervix that can cause bleeding, but it is not a common cause of PPH.
Choice C is wrong because hemorrhoids are swollen veins in the anus or rectum that can cause bleeding, but they are not a common cause of PPH.
Correct Answer is B
Explanation
Prevent infection of the eyes from vaginal bacteria. This is because some newborns can be exposed to bacteria such as gonorrhea or chlamydia during delivery, which can cause a serious eye infection called gonococcal ophthalmia neonatorum (GON). Applying an antibiotic ointment such as erythromycin or ilotycin can prevent GON and other less severe eye infections by killing the bacteria.
Choice A is not correct because the umbilical cord does not need antibiotic ointment to prevent infection. It should be kept clean and dry until it falls off naturally.
Choice C is not correct because the tear ducts are not affected by vaginal bacteria. They are small tubes that drain tears from the eyes to the nose.
Choice D is not correct because the urethra is not a common site of infection for newborns. The urethra is the tube that carries urine from the bladder to the outside of the body.
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