A nurse is caring for a client who experienced a vaginal birth 3 hr ago. Upon palpation, the fundus is displaced to the right of midline, is firm, and is two fingerbreadths above the umbilicus. Which of the following actions should the nurse complete at this time?

Insert a urinary catheter.

Massage the fundus.

Have the client urinate.

Administer an analgesic

Answer and Explanation

The Correct Answer is C

A firm, displaced fundus to the right of midline indicates a full bladder. A distended bladder can prevent the uterus from contracting properly and can lead to uterine atony, increasing the risk of postpartum hemorrhage. Therefore, the priority action is to have the client empty her bladder.
This can often be achieved by encouraging the client to urinate or by assisting her with toileting if necessary. Palpating a fundus that is firm and displaced does not indicate the need for fundal massage, as the fundus is already firm. Inserting a urinary catheter may be necessary if the client is unable to void spontaneously, but this should be done after attempting to have the client

urinate voluntarily. Administering an analgesic is not indicated based on the information provided.

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Correct Answer is C

Explanation

Allowing the baby to drain one breast at each feeding helps ensure effective milk removal, which can alleviate breast engorgement. Emptying the breast thoroughly promotes milk flow and prevents milk stasis, which contributes to engorgement.
A Cold compresses provide temporary relief from discomfort but does not address the underlying cause of engorgement.
B Drinking herbal tea, may have limited evidence supporting its efficacy in reducing engorgement. While hydration is important for breastfeeding, relying solely on herbal tea may not be as effective as other strategies.
D Feeding the baby every 2 hours, is important for maintaining milk supply and preventing engorgement. However, it's essential to ensure the breast is fully drained at each feeding, regardless of the time interval between feedings.

A. Less than 2.5 cm of rubra lochia on perineal pad B. Fundus palpable to right of midline C. Client report of frequent uterine contractions D. Client report of increased thirst

Correct Answer is B

Explanation

One of the signs that the bladder may be distended is when the fundus (top of the uterus) is palpable to the right of the midline. This displacement indicates that the bladder is pushing the uterus to the side, which can occur when the bladder is full and obstructing the descent of the uterus into the pelvis during the postpartum period.

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A nurse is caring for a client who experienced a vaginal birth 3 hr ago. Upon palpation, the fundus is displaced to the right of midline, is firm, and is two fingerbreadths above the umbilicus. Which of the following actions should the nurse complete at this time?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A home health nurse is teaching a client who is breastfeeding about managing breast engorgement. Which of the following client statements indicates understanding of the teaching?

Correct Answer is C

Explanation

A nurse is caring for a client who is 2 hr postpartum following a vaginal birth. Which of the following findings indicates the client's bladder is distended?

Correct Answer is B

Explanation

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