A nurse is assisting in the care of a client who is 4 hr postpartum. Which of the following interventions should the nurse 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 – Correct; a full bladder can displace the uterus and prevent it from contracting effectively.
B. Perform fundal massage – Correct; fundal massage helps stimulate uterine contractions and reduce postpartum bleeding.
C. Nothing, this is an expected finding – Incorrect; a boggy uterus is not expected and requires intervention to prevent hemorrhage.
D. Ambulate the client in the hallway – Incorrect; while ambulation is beneficial postpartum, it is not the immediate intervention for a non-firm uterus.
E. Give pain medications – Incorrect; pain medications do not directly address uterine atony or bleeding.

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Correct Answer is D

Explanation

A. G2 T1 P1 A1 L0 – Incorrect; does not include the current pregnancy.

B. G2 T0 P1 A1 L1 – Incorrect; does not include current pregnancy and incorrectly counts a living child.

C. G3 T0 P1 A1 L1 – Incorrect; incorrectly counts a living child.

D. G3 T0 P1 A1 L0 – Correct; accurately represents her pregnancy history.

A. Encourage the client to nurse more frequently so her milk will come in. B. Report the client's temperature elevation. C. Increase IV fluids. D. Ask the client to empty her bladder.

Correct Answer is D

Explanation

A. Encourage the client to nurse more frequently so her milk will come in. – Incorrect; milk production typically begins between days 2-5 postpartum, not 14 hours postpartum.

B. Report the client's temperature elevation. – Incorrect; a temperature of 37.7°C (100°F) is within normal postpartum range due to dehydration and hormonal shifts.

C. Increase IV fluids. – Incorrect; IV fluids are not needed unless dehydration is suspected.

D. Ask the client to empty her bladder. – Correct; a fundus deviated to the right suggests a full bladder, which can impede uterine involution and increase postpartum hemorrhage risk.

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A nurse is assisting in the care of a client who is 4 hr postpartum. Which of the following interventions should the nurse perform after finding that the client's uterus is not firm? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is 39 weeks in labor. This is her third pregnancy. She reports an early miscarriage at 8 weeks and a stillborn at 36 weeks. What is her GTPAL?

Correct Answer is D

Explanation

A nurse is collecting data from a client who is 14 hr postpartum. The nurse notes: breasts soft; fundus firm, slightly deviated to the right; moderate lochia rubra; temperature 37.7° C (100° F), pulse rate 88./min, respiratory rate 18/min. Which of the following actions should the nurse perform?

Correct Answer is D

Explanation

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