A nurse is collecting data from a client who is 3 hr postpartum.
The nurse notes that the client’s fundus is displaced to the right of midline, is firm, and is two fingerbreadths above the umbilicus.
Which of the following actions should the nurse take?

Insert a urinary catheter.

Massage the fundus.

Have the client urinate.

Administer analgesia.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Inserting a urinary catheter is not the first action to take when the fundus is displaced to the right of midline. The displacement is often due to a full bladder, and the client should be encouraged to void first.

Choice B rationale

Massaging the fundus is appropriate if the uterus is boggy, but in this case, the fundus is firm. The displacement is likely due to a full bladder.

Choice C rationale

Having the client urinate is the correct action. A full bladder can displace the uterus and prevent it from contracting properly, which can lead to postpartum hemorrhage.

Choice D rationale

Administering analgesia is not relevant to the issue of a displaced fundus. The priority is to address the cause of the displacement, which is likely a full bladder.

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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.

A. Have the client ambulate frequently in the hallway. B. Apply warm, moist soaks to the client’s lower legs. C. Keep the client on bed rest. D. Place pillows under the client’s knees while she is resting in bed.

Correct Answer is A

Explanation

Choice A rationale

Ambulation is crucial in preventing thrombophlebitis as it promotes blood circulation and prevents blood stasis, which can lead to clot formation.

Choice B rationale

Warm, moist soaks can provide comfort but do not significantly contribute to preventing thrombophlebitis.

Choice C rationale

Bed rest increases the risk of thrombophlebitis due to decreased circulation and blood stasis.

Choice D rationale

Placing pillows under the knees can impede blood flow and increase the risk of clot formation.

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A nurse is collecting data from a client who is 3 hr postpartum.The nurse notes that the client’s fundus is displaced to the right of midline, is firm, and is two fingerbreadths above the umbilicus.Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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A nurse is collecting data from a client who is 3 hr postpartum.
The nurse notes that the client’s fundus is displaced to the right of midline, is firm, and is two fingerbreadths above the umbilicus.
Which of the following actions should the nurse take?