A nurse is caring for a client who had a vaginal delivery 2 hours ago.
Which of the following actions should the nurse anticipate in the care of this client? (Select all that apply.)
Observe the lochia during palpation of the fundus.
Massage a firm fundus.
Determine whether the fundus is midline.
Document fundal height.
Administer methylergonovine maleate.
Correct Answer : A,C,E
Step 1: The nurse should observe the lochia during palpation of the fundus. This can help assess the amount and type of vaginal discharge after childbirth.
Step 2: The nurse should not massage a firm fundus. If the uterus is firm, it means it is contracting well to control bleeding.
Step 3: The nurse should determine whether the fundus is midline. A uterus that is not midline may indicate a full bladder, which can interfere with uterine contraction and lead to increased bleeding.
Step 4: Documenting fundal height is not typically done postpartum. Instead, the nurse assesses whether the fundus is firm and midline.
Step 5: The nurse should administer methylergonovine maleate if the uterus is boggy. This medication helps the uterus contract to control bleeding.
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Related Questions
Correct Answer is A
Explanation
Choice A rationale
Given the frequency and duration of the contractions, along with the maternal and fetal vital signs, it is important to notify the healthcare provider immediately. These could be signs of labor progression and the healthcare provider can provide further instructions based on the clinical situation.
Choice B rationale
While managing pain is important, the priority in this situation is to communicate with the healthcare provider due to the frequency of contractions and the vital signs.
Choice C rationale
Having the patient void is not the priority in this situation. While a full bladder can affect labor progression, the frequency of contractions and the vital signs take precedence.
Choice D rationale
Positioning the patient with one hip elevated is not the priority in this situation. This position is often used to alleviate supine hypotensive syndrome, but the patient’s blood pressure is not indicating this condition.
Correct Answer is C
Explanation
Choice A rationale
While accidental lacerations can occur during a cesarean delivery, they are not typically the primary concern immediately after delivery.
Choice B rationale
Acrocyanosis, or bluish discoloration of the hands and feet, is common in newborns and is not typically a priority concern immediately after delivery.
Choice C rationale
Respiratory distress is a priority concern in a newborn after a cesarean delivery. Newborns delivered by cesarean may have transient tachypnea of the newborn (TTN), a condition characterized by rapid breathing during the first few hours of life.
Choice D rationale
While hypothermia is a concern in newborns, it is not typically the immediate priority following a cesarean delivery.
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