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
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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Related Questions
Correct Answer is A
Explanation
A. Massaging the client's back – Correct; gate control theory states that non-painful stimuli (e.g., massage, heat, cold) can block pain signals from reaching the brain.
B. Administering prescribed analgesic medication – Incorrect; this is pharmacologic pain relief, not part of gate control theory.
C. Turning the client onto her left side – Incorrect; this improves circulation but does not block pain signals.
D. Encouraging the client to rest between contractions – Incorrect; rest is important but does not directly affect pain perception.
Correct Answer is ["B","D","E"]
Explanation
A. The amniotic fluid produces hormones necessary for fetal development. – Incorrect; the placenta, not the amniotic fluid, is responsible for hormone production.
B. The amniotic fluid regulates the temperature of the fetus. It helps maintain a constant temperature. – Correct; amniotic fluid provides thermal regulation for the fetus.
C. The amniotic fluid aids in digestion and absorption of nutrients. – Incorrect; the fetus obtains nutrients via the placenta, not the amniotic fluid.
D. The amniotic fluid cushions and protects the fetus. – Correct; amniotic fluid acts as a shock absorber, protecting the fetus from trauma.
E. Amniotic fluid allows the fetus to move freely. Aids in symmetric growth by providing an unrestricted environment. – Correct; amniotic fluid prevents fetal deformities by allowing movement and growth.
F. The amniotic fluid regulates the fetal heart rate. – Incorrect; fetal heart rate is regulated by the autonomic nervous system and placental function, not amniotic fluid.
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