A nurse is caring for a client who had a vaginal delivery 2 hr ago. Which of the following actions should the nurse anticipate in the care of this client? (Select all that apply.)
Massage a firm fundus.
Determine whether the fundus is midline.
Document fundal height.
Observe the lochia during palpation of fundus.
Administer methylergonovine maleate if uterus is boggy.
Correct Answer : B,C,D,E
Answer: B, C, D, E
Rationale:
A) Massage a firm fundus: If the fundus is already firm, routine massage is not necessary. Instead, the nurse should monitor the fundus for firmness and position. Massaging is indicated only if the fundus is boggy or atonic to promote uterine contraction.
B) Determine whether the fundus is midline: Checking the position of the fundus is essential to assess for potential complications. A fundus that is not midline could indicate bladder distention, which can interfere with uterine contraction and lead to postpartum hemorrhage.
C) Document fundal height: Documenting the height of the fundus is important for monitoring uterine involution. The fundus should be at the level of the umbilicus 1-2 hours postpartum, and any deviation from expected findings should be noted for ongoing assessment.
D) Observe the lochia during palpation of fundus: Observing lochia during fundal assessment helps identify potential complications such as excessive bleeding or clots. It is crucial for the nurse to monitor lochia in conjunction with fundal assessment to ensure appropriate postpartum recovery.
E) Administer methylergonovine maleate if the uterus is boggy: Methylergonovine is indicated for uterine atony (a boggy uterus) to promote uterine contractions and reduce the risk of postpartum hemorrhage. If the fundus is found to be boggy during assessment, administration of this medication should be anticipated.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A) The client is carrying more than one fetus:
This condition is known as polyzygotic multiples (e.g., twins, triplets) and is not the definition of polyhydramnios. Polyhydramnios refers specifically to the excessive accumulation of amniotic fluid in a singleton pregnancy.
B) There is an elevated level of alpha-fetoprotein (AFP) in the amniotic fluid:
An elevated level of alpha-fetoprotein (AFP) in the amniotic fluid is associated with neural tube defects and other fetal abnormalities. However, this is not the definition of polyhydramnios.
C) The fetus is likely to have a congenital anomaly, be growth restricted, or demonstrate fetal distress during labor:
While polyhydramnios can sometimes be associated with fetal anomalies, growth restriction, or fetal distress during labor, it is not the primary definition of the condition. Polyhydramnios itself refers to the excessive accumulation of amniotic fluid, and its presence does not always indicate fetal anomalies or distress. However, these associations may require further evaluation and monitoring during pregnancy.
D) An excessive amount of amniotic fluid is present:
Polyhydramnios is a condition characterized by an excessive accumulation of amniotic fluid around the fetus. This excess fluid can lead to complications during pregnancy and labor, including preterm labor, premature rupture of membranes, and postpartum hemorrhage. It can also be associated with maternal diabetes, fetal anomalies, or other underlying maternal or fetal conditions.
Correct Answer is B
Explanation
B) Continuous contraction lasting 2 min:
Continuous contractions lasting for 2 minutes can indicate uterine hyperstimulation, which is an abnormal finding and requires immediate intervention. Hyperstimulation can reduce fetal oxygenation and lead to fetal distress. The nurse should report this finding to the provider promptly to prevent potential complications.
A) Expulsion of clear fluid from the vagina:
Expulsion of clear fluid from the vagina indicates the rupture of membranes, which is a normal part of the first stage of labor. While this finding should be documented and monitored, it does not require immediate intervention.
C) Pressure on the perineum causing the client to bear down:
Pressure on the perineum causing the client to bear down indicates the client is experiencing the urge to push (fetal descent). This is a normal finding during the first stage of labor as the cervix dilates. While it's an important finding, it does not indicate an immediate concern.
D) Expulsion of a blood-tinged mucous plug:
Expulsion of a blood-tinged mucous plug (bloody show) is also a normal finding during the first stage of labor and indicates cervical changes. While this finding should be documented, it does not require immediate intervention.
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