A nurse is performing an assessment on a postpartum patient.
The uterus is found to be displaced to the right.
Which of the following actions should the nurse take?

Action A.

Action B.

Action C.

Action D.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Placing the mother in Trendelenburg's position would not correct the uterine displacement. Trendelenburg's position involves

lowering the head of the bed and raising the feet, which can actually worsen uterine displacement by increasing pressure on

the uterus from the abdominal organs.

It is not indicated for uterine displacement and could potentially have adverse effects on the patient's hemodynamic status

and respiratory function.

Choice C rationale:

Notifying the physician is important, but it is not the first action the nurse should take.

The nurse should assess the patient and attempt to correct the displacement before notifying the physician.

Choice D rationale:

Recording the findings is important for documentation, but it is not an intervention that will correct the uterine displacement.

Choice B rationale:

Massaging the fundus is the correct action to take when a postpartum uterus is displaced.

The fundus is the top of the uterus, and massaging it can help to stimulate the uterine muscles to contract and return to their

normal position.

This is often effective in correcting mild to moderate uterine displacements.

Here are the steps involved in massaging the fundus:

Locate the fundus: The nurse should first locate the fundus by palpating the abdomen just below the umbilicus.

Apply gentle pressure: Once the fundus is located, the nurse should apply gentle pressure with the fingertips in a circular

motion.

Continue massaging: The massage should be continued for several minutes, or until the uterus is felt to be firm and in the

midline position.

Additional notes:

If the uterine displacement is severe, or if the patient is experiencing pain or bleeding, the nurse should notify the physician

immediately.

Other interventions that may be used to correct uterine displacement include:

Assisting the patient to empty her bladder

Straight catheterization

Administration of oxytocin to stimulate uterine contractions

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Correct Answer is B

Explanation

Choice A rationale:

Elevating the client's legs can improve venous return and cardiac output, but it does not directly address the underlying cause

of late decelerations, which is uteroplacental insufficiency.

While elevating the legs may have some benefit, it's not the most effective initial action to address late decelerations.

It's important to prioritize interventions that directly improve uteroplacental blood flow.

Choice C rationale:

Increasing the infusion rate of IV fluids can expand maternal blood volume, but it may not significantly improve uteroplacental

perfusion if there's underlying placental insufficiency.

It's not the most effective initial action to address late decelerations.

It may be considered as a secondary measure if repositioning doesn't resolve the decelerations.

Choice D rationale:

Administering oxygen via face mask can improve fetal oxygenation, but it does not directly address the underlying cause of

late decelerations, which is uteroplacental insufficiency.

It's not the most effective initial action to address late decelerations.

It may be considered as an adjunct measure to improve fetal oxygenation, but it's not a primary intervention for late

decelerations.

Choice B rationale:

Positioning the client on her side is the most effective initial action to address late decelerations because it:

Relieves pressure on the vena cava, which improves venous return and cardiac output.

Increases placental perfusion by increasing blood flow to the uterus.

This can help to correct fetal hypoxia and improve fetal heart rate patterns.

It's a simple, non-invasive intervention that can be quickly implemented and has a high success rate in resolving late

decelerations.

A. Gestational hypertension B. Small for gestational age newborn C. Precipitous birth D. Two-vessel umbilical cord

Correct Answer is C

Explanation

Choice A rationale:

Gestational hypertension is a condition characterized by elevated blood pressure during pregnancy. While it can increase the

risk of certain complications, it is not directly associated with an increased risk of postpartum hemorrhage. This is because

gestational hypertension primarily affects the vascular system, not the uterine muscle function, which is responsible for

controlling postpartum bleeding.

Choice B rationale:

A small for gestational age newborn (SGA) is a baby who is smaller than expected for their gestational age. While SGA can be

associated with some pregnancy complications, it is not a direct risk factor for postpartum hemorrhage. The size of the baby

does not have a significant impact on the ability of the uterus to contract and prevent excessive bleeding after delivery.

Choice C rationale:

Precipitous birth is defined as a labor that progresses very rapidly, with delivery occurring within three hours or less of the

onset of regular contractions. This rapid progression of labor can lead to postpartum hemorrhage for several reasons:

Uterine atony: The uterus may not have enough time to contract effectively after a rapid delivery, leading to increased

bleeding.

Lacerations and trauma: The rapid passage of the baby through the birth canal can increase the risk of tearing of the cervix,

vagina, or perineum, which can contribute to blood loss.

Retained placenta: The placenta may not separate from the uterine wall as easily after a precipitous birth, increasing the risk

of hemorrhage.

Choice D rationale:

A two-vessel umbilical cord is a variation in which the umbilical cord contains only two blood vessels (one vein and one

artery) instead of the usual three (one vein and two arteries). While this can be associated with certain fetal anomalies, it is not

a direct risk factor for postpartum hemorrhage. The number of blood vessels in the umbilical cord does not significantly

impact the ability of the uterus to contract and prevent bleeding after delivery.

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A nurse is performing an assessment on a postpartum patient. The uterus is found to be displaced to the right.Which of the following actions should the nurse take?

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A nurse is performing an assessment on a postpartum patient. The uterus is found to be displaced to the right.Which of the following actions should the nurse take?

A nurse is performing an assessment on a postpartum patient.
The uterus is found to be displaced to the right.
Which of the following actions should the nurse take?