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

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

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. 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.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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 caring for a client who is 14 hours postpartum.The nurse notes that the client’s breasts are soft, the fundus is firm and slightly deviated to the right, and the client’s pulse rate is 88/min with a respiratory rate of 18/min.Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is reviewing the medical record of a client who experienced a vaginal birth 2 hours ago.The nurse should identify that which of the following findings places the client at risk for a postpartum hemorrhage?

Correct Answer is C

Explanation

A nurse is assisting in the care of a client who is at 38 weeks of gestation. What condition is the client most likely experiencing, what are 2 actions the nurse should take to address that condition, and what are 2 parameters the nurse should monitor to assess the client’s progress?

A nurse is caring for a client who has unrelieved episiotomy pain 8 hours following delivery. Which of the following actions should the nurse take?

A nurse is caring for a postpartum client following a vaginal birth of a newborn weighing 4252 g (9 lb 6 oz). The nurse should identify that this client is at risk for which of the following postpartum complications?

A nurse is caring for a client who is postpartum. Which of the following findings is an indication for the nurse to administer Rho(D) immune globulin?

A nurse is assisting with the care of a client who is in the second stage of labor.The nurse observes retraction of the fetal head against the maternal perineum as the head is birthed. Which of the following actions should the nurse take?

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?

A nurse is collecting data from a postpartum client. Which of the following findings should alert the nurse to the possibility of a postpartum complication?

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?