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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Related Questions
Correct Answer is A
Explanation
The correct answer is choice E) Signs of peritonitis.
Peritonitis is an inflammation of the lining of the abdominal cavity that can be caused by an infection or a perforation of an organ.
It can cause severe abdominal pain and tenderness, fever, nausea, vomiting, and decreased bowel sounds.Peritonitis is a medical emergency that requires immediate treatment with antibiotics and surgery
Choice A) Bowel sounds is wrong because bowel sounds are normal and expected after a cesarean section.
They indicate that the intestines are functioning properly and moving food and gas through the digestive tract.Bowel sounds may be decreased or absent if there is an obstruction, ileus, or peritonitis
Choice B) Lochia amount is wrong because lochia is the vaginal discharge that occurs after childbirth.
It consists of blood, mucus, and tissue from the uterus.
Lochia amount is not related to abdominal pain and tenderness after a cesarean section.
Lochia amount may vary depending on the stage of lochia (rubra, serosa
Correct Answer is A
Explanation
The correct answer is choice A) Document findings as normal.
The fundus is the upper part of the uterus that contracts after delivery to prevent bleeding.The fundus should be firm, midline, and at the level of the umbilicus or lower on the second postpartum day.Lochia rubra is the normal bloody discharge that occurs for the first few days after delivery and should not contain large clots.The normal range of lochia rubra is scant to moderate.
Choice B) Massage fundus until it becomes firm is wrong because the fundus is already firm and does not need further stimulation.
Choice C) Administer oxytocin (Pitocin) is wrong because oxytocin is a medication that helps the uterus contract and is not indicated for a firm fundus.
Choice D) Increase IV fluid rate is wrong because IV fluids are not related to the assessment of the fundus and lochia and may cause fluid overload.
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