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 A

Explanation

Choice A rationale:

Heavy vaginal bleeding in late pregnancy, especially at 39 weeks of gestation, is a medical emergency that requires immediate

intervention.

It can be a sign of placental abruption, a serious condition in which the placenta separates from the uterine wall prematurely.

Placental abruption can lead to fetal distress and maternal hemorrhage, both of which can be life-threatening.

Cesarean birth is the quickest and safest way to deliver the baby in this situation.

It allows the healthcare team to control the bleeding and prevent further complications.

Delaying a cesarean birth can put the mother and baby at increased risk.

Choice B rationale:

Antibiotics are not indicated for heavy vaginal bleeding in late pregnancy.

They are used to treat infections, not bleeding.

There is no evidence to suggest that the client has an infection.

Choice C rationale:

Magnesium sulfate is a medication used to prevent seizures in women with preeclampsia.

It is not indicated for heavy vaginal bleeding.

There is no evidence to suggest that the client has preeclampsia.

Choice D rationale:

A cervical examination is not necessary in this situation.

The priority is to deliver the baby as quickly as possible.

A cervical examination would only delay the delivery.

A. Check the client's blood pressure B. Massage the client's fundus C. Observe for pooling of blood under the buttocks D. Administer oxytocin

Correct Answer is B

Explanation

Choice A rationale:

Checking the client’s blood pressure is important, but it is not the first action the nurse should take. Hypotension could

indicate hemorrhage, but the nurse needs to address the immediate risk of excessive bleeding.

Choice B rationale:

The nurse should first massage the client’s fundus. A saturated perineal pad could indicate a postpartum hemorrhage.

Massaging the fundus helps the uterus contract and may stop the bleeding.

Choice C rationale:

Observing for pooling of blood under the buttocks is a way to assess for bleeding. However, this is not the first action because

it does not address the cause of the bleeding.

Choice D rationale:

Administering oxytocin can help the uterus contract and reduce bleeding. However, this is not the first action because it

requires a physician’s order.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the admission of a client who is at 39 weeks of gestation and has heavy vaginal bleeding. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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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?