A nurse is collecting data from a client who gave birth 12 hr ago.
The nurse notes the fundus is deviated to the right, boggy, and 2 cm above the umbilicus.
Which of the following actions should the nurse take first?
Insert an indwelling urinary catheter.
Administer methylergometrine to the client.
Obtain a stat hemoglobin level.
Assist the client to void.
The Correct Answer is D
Choice D rationale
Assisting the client to void is the first action the nurse should take. A full bladder can cause the fundus to deviate to the right and become boggy. Voiding helps the uterus contract and return to its normal position.
Choice A rationale
Inserting an indwelling urinary catheter may be necessary if the client is unable to void, but it is not the first action.
Choice B rationale
Administering methylergometrine to the client is not the first action. This medication stimulates uterine contractions and can help reduce postpartum bleeding, but the initial step is to address the full bladder.
Choice C rationale
Obtaining a stat hemoglobin level is important if there is a concern for significant blood loss, but it is not the first action.
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Related Questions
Correct Answer is C
Explanation
Choice A rationale
While sharing personal experiences can sometimes be comforting, it may not always be appropriate or helpful in a professional setting. The focus should be on the patient’s needs and feelings.
Choice B rationale
Calling for a chaplain can be supportive, but it is important to first offer the parents the opportunity to hold their baby and spend time with them, which can be an important part of the grieving process.
Choice C rationale
Allowing the parents to hold their baby for as long as they want provides them with the opportunity to say goodbye and can be a crucial part of the grieving process. It helps them to acknowledge their loss and begin to process their emotions.
Choice D rationale
Telling the parents that the loss is for the best is not supportive and can be hurtful. It is important to validate their feelings and provide compassionate care during this difficult time. .
Correct Answer is C
Explanation
Choice C rationale
Massaging the fundus helps the uterus contract and can reduce bleeding, which is crucial in managing postpartum hemorrhage.
Choice A rationale
Checking blood pressure is important but not the first action to control bleeding.
Choice B rationale
Observing the client is necessary but not the immediate action to control bleeding.
Choice D rationale
Administering oxytocin is important but should follow fundal massage to ensure the uterus is contracting.
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