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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.

Answer and Explanation

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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Correct Answer is B

Explanation

B) Assist the client to the bathroom to void:
A slightly boggy and displaced fundus to the right suggests a full bladder. A full bladder can displace the uterus and interfere with uterine contractions, leading to uterine atony. Therefore, the nurse should assist the client to the bathroom to void. Emptying the bladder will help the uterus to contract properly and return to its midline position.

A) Ask the client to rate her pain:
Pain assessment is important for overall client care but is not the priority in this situation. The displacement of the fundus suggests a physiological issue rather than pain being the primary concern.

C) Encourage the client to move to the left lateral position:
While positioning can assist with uterine displacement in some cases, the priority action is to address the full bladder. Once the client has emptied her bladder, the nurse can encourage a left lateral position to help optimize uterine contraction.

D) Encourage the client to perform Kegel exercises:
Kegel exercises are not indicated for addressing a boggy and displaced fundus. These exercises are typically used to strengthen the pelvic floor muscles, which can help with urinary incontinence and promote healing postpartum. However, they will not directly address the issue of a displaced fundus caused by a full bladder.

A. Report of pain above the umbilicus B. Amniotic fluid in the vaginal vault C. Brownish vaginal discharge D. Cervical dilation

Correct Answer is D

Explanation

A. Report of pain above the umbilicus: Pain above the umbilicus is not a definitive sign of labor. Pain during labor typically originates in the lower abdomen and back, as the uterus contracts to facilitate cervical dilation and effacement.

B. Amniotic fluid in the vaginal vault: While the rupture of membranes (amniotic fluid leaking) can be a sign of labor, its presence alone does not confirm active labor. Labor is typically confirmed by progressive cervical changes, such as dilation and effacement.

C. Brownish vaginal discharge: Brownish vaginal discharge could indicate the presence of old blood, which might be a sign of bloody show, but it alone does not confirm active labor. Labor is typically confirmed by progressive cervical changes, such as dilation and effacement.

D. Cervical dilation: Cervical dilation is one of the primary indicators of labor. In a primigravida at 42 weeks of gestation who believes she is in labor, cervical dilation would confirm the onset of labor.

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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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is postpartum and finds the fundus slightly boggy and displaced to the right. Based on these findings, which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse midwife is examining a client who is a primigravida at 42 weeks of gestation and states that she believes she is in labor. Which of the following findings confirm to the nurse that the client is in labor?

Correct Answer is D

Explanation

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