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.
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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 the instructions that the nurse should include in the teaching for a client who had a vaginal delivery with a midline episiotomy.
• Choice A is correct because using a sitz bath three times per day and after each bowel movement can help reduce pain, swelling and infection of the perineum.
• Choice C is correct because applying ice packs to the perineum for the first 24 hours can help reduce inflammation and bleeding.
• Choice D is correct because performing Kegel exercises several times per day can help strengthen the pelvic floor muscles and improve urinary continence.
• Choice E is correct because reporting any increase in redness, swelling or discharge from the episiotomy site can help detect signs of infection or wound breakdown.
• Choice B is wrong because wiping from back to front after voiding or having a bowel movement can increase the risk of infection by introducing bacteria from the anal area to the vaginal area.The correct way to wipe is from front to back.
Correct Answer is A
Explanation
The correct answer is choice A.The woman should change her perineal pad every time she uses the bathroom to prevent infection and promote healing of the perineal area.
Some possible explanations for the other choices are:
• Choice B is wrong because the woman should wipe her perineum from front to back after urinating or defecating to avoid introducing bacteria from the anus to the vagina or urethra.
• Choice C is wrong because the woman should apply ice packs on her perineum for the first 24 hours after birth, not for the first week.
Ice packs help reduce swelling and pain in the per
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