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?
Encourage the client to perform Kegel exercises.
Encourage the client to move to the left lateral position.
Ask the client to rate her pain.
Encourage the client to empty bladder by voiding
The Correct Answer is D
A. Kegel exercises are not indicated for addressing a boggy uterus; emptying the bladder is a more appropriate intervention.
B. Moving to the left lateral position may help, but the primary concern is a full bladder contributing to uterine displacement.
C. Pain assessment is important but does not directly address the issue of a boggy uterus and displacement.
D. Encouraging the client to empty the bladder by voiding is essential, as a full bladder can displace the uterus and contribute to uterine atony.
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Related Questions
Correct Answer is C
Explanation
A. Changing the perineal pad of a client who has just been transferred from the labor ward is a task that should not be delegated to an assistive personnel (AP) since it is beyond their scope.
B. Monitoring vital signs during the admission of a client with gestational hypertension requires nursing judgment and assessment skills.
C. Providing a sitz bath to a client with a fourth-degree laceration and is 2 days post- partum can be delegated to an AP. This task does not require the nurse's clinical judgment or assessment skills, and it can be safely performed by the AP following the nurse's instructions.
D. Observing an area of redness on the breast requires nursing assessment and intervention.
Correct Answer is ["A","D","E"]
Explanation
A. Hepatitis B immunization is typically administered soon after birth for protection.
B. Hib immunization is usually given later and not immediately after birth.
C. Lidocaine gel is not routinely used on the umbilical stump.
D. Vitamin K injection is commonly given to prevent bleeding disorders in newborns.
E. Antibiotic ointment to both eyes prevents eye infections that can be caused by bacteria transmitted from the mother during delivery.
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