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:

A full bladder can displace the uterus to the right and interfere with its ability to contract properly. This can lead to

postpartum hemorrhage, a serious complication that can occur after childbirth.

Emptying the bladder helps to reposition the uterus in the midline and allows it to contract more effectively. This helps to

prevent postpartum hemorrhage and promotes uterine involution, the process by which the uterus returns to its pre-

pregnancy size.

In this case, the client's fundus is firm, which indicates that it is contracting well. However, it is slightly deviated to the right,

which suggests that the bladder may be full.

Asking the client to empty her bladder is a simple and effective way to address this potential problem.

Choice B rationale:

Repeating the client's temperature evaluation is not a priority action in this case. The client's vital signs are within normal

limits, and there is no indication of infection.

A temperature elevation could be a sign of infection, but it is not the most likely cause of the uterine deviation in this case.

Choice C rationale:

Encouraging the client to nurse more frequently may be helpful in stimulating milk production and uterine contractions.

However, it is not the most immediate priority in this case.

The client's breasts are soft, which suggests that she is not yet producing a significant amount of milk.

The priority is to address the potential problem of a full bladder, which could interfere with uterine involution.

Choice D rationale:

Checking for signs of a urinary tract infection is not a priority action in this case. The client does not have any urinary

symptoms, such as dysuria or frequency.

A urinary tract infection could cause a uterine deviation, but it is not the most likely cause in this case.

A. Elevate the client’s legs. B. Position the client on her side. C. Increase the infusion rate of the IV fluid. D. Administer oxygen via face mask.

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.

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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?