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 C

Explanation

A. "Epidurals are best because they provide complete pain relief." – Incorrect; while epidurals provide significant pain relief, they may not be the best option for every client.
B. "Most women need IV pain medications at some point during labor." – Incorrect; pain management is individualized, and not all women require IV pain medication.
C. "It is best to learn about the different types of pain relief available, as every woman experiences labor pain differently." – Correct; pain relief options should be tailored to the individual's preferences and medical condition.
D. "There is no one best way. However, natural childbirth is best for the baby." – Incorrect; while natural childbirth is an option, it is not necessarily the best choice for everyone.

A. Pressure from the growing uterus displaces the stomach. B. Increased pancreatic activity results in intolerance of fat in the diet. C. Increased progesterone production causes decreased motility of smooth muscle. D. Increased estrogen production causes increased secretion of hydrochloric acid.

Correct Answer is C

Explanation

A. Lightening – Correct; "lightening" occurs when the fetal head descends into the pelvis, reducing pressure on the diaphragm, making it easier to breathe.

B. Decreasing chest diameter – Incorrect; the chest diameter does not decrease; instead, the diaphragm moves upward due to uterine growth.

C. Decreased carbon dioxide production – Incorrect; CO₂ production remains stable during pregnancy.

D. Hyperventilation – Incorrect; while pregnancy increases respiratory effort, the client is experiencing relief, not hyperventilation.

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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.)

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