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
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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Related Questions
Correct Answer is A
Explanation
Hypotension is a common complication associated with epidural anesthesia in labor. When the epidural anesthesia is administered, it can cause vasodilation, which can lead to a decrease in blood pressure. This decrease in blood pressure can result in hypotension. Measures such as administering intravenous fluids and positioning the client on her left side can help mitigate this complication. Vomiting, tachycardia, and respiratory depression are less common complications associated with epidural anesthesia in labor.
Correct Answer is D
Explanation
A fetal heart rate of 158/min is within the normal range for a fetus.
B. Respirations of 16/min are within the normal range for an adult.
C. Headache can be a symptom of pre-eclampsia, but it does not necessarily indicate magnesium toxicity.
D. Decreased urinary output can indicate renal insufficiency or impaired kidney function, which can be a sign of magnesium toxicity.
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