A nurse in a hospital is caring for a client who is 4 hour postpartum. Which of the following interventions should the nurse first perform after finding that the client's uterus is not firm? (Select All that Apply.)

Ask the client to empty their bladder

Perform fundal massage

Nothing, this is an expected finding

Ambulate the client in the hallway

Give pain medications

Answer and Explanation

Correct Answer : A,B

A) Ask the client to empty their bladder:
One of the first actions the nurse should take when the uterus is not firm (often referred to as uterine atony) is to ask the client to empty their bladder. A full bladder can interfere with uterine contraction and cause the uterus to be boggy or soft, which can lead to postpartum hemorrhage. Encouraging the client to void may help the uterus contract more effectively and reduce the risk of complications.

B) Perform fundal massage:
If the uterus is not firm, performing a fundal massage is essential. Fundal massage helps stimulate uterine contractions and helps the uterus contract to its normal size, reducing the risk of bleeding. It is a critical intervention in postpartum care to ensure that the uterus remains firm and does not become atonic, which can cause excessive blood loss.

C) Nothing, this is an expected finding:
A soft uterus (uterine atony) is not an expected finding 4 hours postpartum. A firm uterus is expected at this point to prevent hemorrhage. The nurse should take immediate action to address the issue of uterine atony, as failure to do so can lead to significant postpartum hemorrhage, a life-threatening complication.

D) Ambulate the client in the hallway:
Ambulation may be helpful later in the postpartum period to encourage circulation and prevent thromboembolism, but it is not a priority when the uterus is not firm. The first priority is to address uterine atony, and actions like emptying the bladder and massaging the fundus should be performed before ambulating the client.

E) Give pain medications:
While pain management is important, it is not the priority intervention when the uterus is not firm. The nurse must first address the cause of uterine atony (such as bladder distention) and stimulate uterine contractions via fundal massage to ensure that the uterus is firm and the client is not at risk for excessive bleeding. Pain medications can be given once the immediate uterine concerns have been addressed.

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Correct Answer is D

Explanation

A) Offering opioids followed by topical treatment:
While opioids can be effective for pain, they are typically reserved for more severe pain and are not the first line of treatment for the moderate pain commonly experienced postpartum, especially after a first-degree laceration. A stepwise approach emphasizes starting with less potent options and progressing as needed, so offering opioids first is not appropriate here.

B) Offering mindfulness only for pain:
While mindfulness and other non-pharmacological techniques can be helpful for pain management, offering only mindfulness as the sole approach may not adequately address the client's pain, especially in the early postpartum period. A stepwise approach typically involves combining pharmacological and non-pharmacological methods to achieve effective pain relief, so relying only on mindfulness is not the most effective strategy for this situation.

C) Giving the highest dose of opioids to make sure to eliminate the pain:
Stepwise pain management involves starting with the least invasive and least potent option, such as nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen, and escalating treatment if necessary. Using high doses of opioids first can lead to unnecessary side effects and risks, especially when less potent options would suffice.

D) Starting with ibuprofen for pain management and adding cold therapy for additional relief:
This is an example of a stepwise approach to pain management. Starting with ibuprofen, an NSAID, addresses inflammation and mild to moderate pain effectively, which is appropriate for a first-degree laceration. Cold therapy can be added for additional relief, as it helps reduce swelling and numb the area, which can further reduce discomfort. This combination of pharmacological and non-pharmacological treatments follows the principle of starting with less potent options and adding more if needed, making it the best choice.

A. June 10 B. June 24 C. June 20 D. June 14

Correct Answer is B

Explanation

Naegele's Rule is a method used to estimate the due date of a pregnancy. It involves the following steps:

Start with the first day of the client's last menstrual period (LMP).
Add one year.
Subtract three months.
Add seven days.

Using the client's LMP of September 17:

Start with September 17.
Add one year: September 17, the following year.
Subtract three months: June 17 of the following year.
Add seven days: June 24.

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A nurse in a hospital is caring for a client who is 4 hour postpartum. Which of the following interventions should the nurse first perform after finding that the client's uterus is not firm? (Select All that Apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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