A nurse is assessing a postpartum client who delivered vaginally 2 days ago and notes that her fundus is boggy and displaced to the right side of her abdomen.
Which of the following actions should the nurse take first?
Administer oxytocin as prescribed
Assist with ambulation.
Encourage frequent voiding
Massage her fundus
The Correct Answer is D
The correct answer is choice D. Massage her fundus.
This is because a boggy and displaced fundus indicates uterine atony, which is the failure of the uterus to contract sufficiently after delivery.
This can lead to excessive bleeding and postpartum hemorrhage. Massaging the fundus can help stimulate uterine contractions and reduce blood loss.
Choice A is wrong because administering oxytocin is not the first action the nurse should take. Oxytocin is a medication that can also help the uterus contract, but it should be given after massaging the fundus and assessing the bleeding.
Choice B is wrong because assisting with ambulation is not appropriate for a client with a boggy and displaced fundus. Ambulation can increase bleeding and cause orthostatic hypotension due to blood loss.
Choice C is wrong because encouraging frequent voiding is not the first action the nurse should take.
A full bladder can displace the uterus and prevent effective contractions, so voiding can help the uterus return to its normal position. However, this should be done after massaging the fundus and assessing the bleeding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D","E"]
Explanation
The correct answer is choice A, C, D and E. These are all non-pharmacological methods of pain relief that can be used during labor.They work by providing natural pain relief, increasing endorphins, creating competing impulses in the nervous system, or reducing muscle tension and anxiety.
Choice B, biofeedback, is wrong because it is a technique that involves monitoring and controlling physiological responses such as heart rate, blood pressure, muscle tension, and brain waves.It requires special equipment and training and is not commonly used during labor.
Normal ranges for pain during labor vary depending on the individual, the stage of labor, and the method of pain relief.Some factors that can influence pain perception are fear, anxiety, fatigue, previous experiences, expectations, and coping skills.
Correct Answer is A
Explanation
The correct answer is choice A) Encourage fluid intake to promote hydration.
This is because hydration helps to flush out the infection and prevent dehydration from fever.
Fluid intake also supports milk production for breastfeeding.
Choice B) Instruct the client to avoid ambulation until symptoms resolve is wrong because ambulation promotes blood circulation and prevents thrombosis.
Ambulation also helps to expel lochia and reduce uterine cramping.
Choice C) Administer analgesics as prescribed to manage pain is correct but not the best answer.
Pain management is important for comfort and healing, but it does not address the underlying infection.
Choice D) Instruct the client to avoid breastfeeding until symptoms resolve is wrong because breastfeeding helps to contract the uterus and prevent bleeding.
Breastfeeding also provides immunity and nutrition to the newborn.
The infection is not transmitted through breast milk.
Choice E) Encourage frequent voiding is correct but not the best answer.
Frequent voiding helps to prevent urinary tract infections and bladder distension.
However, it does not directly affect the endometrial infection.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.