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.
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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Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Umbilical cord compression is the most common cause of variable decelerations. It occurs when the umbilical cord is
compressed, momentarily reducing blood flow to the fetus and causing a decrease in fetal heart rate.
Variable decelerations are characterized by their abrupt onset, variable duration, and unpredictable shape. They typically
recover quickly to the baseline fetal heart rate after the compression is relieved.
Several factors can contribute to umbilical cord compression, including:
Fetal movement: The fetus can sometimes move in a way that compresses the cord, especially during active labor.
Oligohydramnios (low amniotic fluid): With less amniotic fluid, there's less cushioning around the cord, making it more prone
to compression.
Nuchal cord (cord around the neck): If the cord is wrapped around the fetus's neck, it can become compressed during
contractions.
Short umbilical cord: A shorter cord has less slack, increasing the risk of compression.
Choice B rationale:
Maternal hypotension can cause fetal heart rate decelerations, but these typically present as late decelerations, not variable
decelerations. Late decelerations have a gradual onset, a uniform shape, and typically occur after the peak of a contraction.
Maternal hypotension can decrease placental blood flow, leading to fetal hypoxia (decreased oxygen supply). This hypoxia can
then trigger a decrease in fetal heart rate.
Choice C rationale:
The fetal sleep cycle does not typically cause variable decelerations in the fetal heart rate. During sleep, the fetal heart rate
may exhibit a decrease in baseline variability, but this is not the same as variable decelerations.
Choice D rationale:
The use of epidural anesthesia can sometimes cause a decrease in fetal heart rate variability, but it does not typically cause
variable decelerations. Epidural anesthesia can lead to maternal hypotension, which, as mentioned earlier, can cause late
decelerations.
Correct Answer is D
Explanation
Choice A rationale:
Evaluating the side effects of analgesia is not the priority action in this situation. While it's important to assess for potential
side effects, the client's immediate need to use the bathroom takes precedence.
Analgesia might contribute to urinary retention in some cases, but it's not the most likely reason for the client's request.
Promptly addressing the client's need to void helps prevent bladder distention, discomfort, and potential urinary tract
infections.
Choice B rationale:
Using a wheelchair is not necessary in most cases after a vaginal birth.
Early ambulation is generally encouraged to promote circulation, prevent blood clots, and aid in recovery.
Requiring a wheelchair could delay the client's ability to void and might make her feel less independent.
Choice C rationale:
Advising the client to remain in bed is not recommended practice after a vaginal birth.
Prolonged bed rest can increase the risk of complications, such as blood clots, muscle weakness, and delayed bowel function.
Early ambulation, as tolerated, is crucial for promoting physical recovery and preventing postpartum complications.
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