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
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
Choice A rationale:
The client is in the second stage of labor because she is actively pushing and the fetal head is at the vaginal station.
The second stage of labor is defined as the time from full cervical dilation to the birth of the baby. It is characterized by strong,
regular contractions and the urge to push.
Decelerations in the fetal heart rate can occur during the second stage of labor due to a variety of factors, including head
compression, cord compression, and uteroplacental insufficiency.
Choice B rationale:
The nurse should apply an oxygen mask to the client to increase the oxygen supply to the fetus.
This can help to improve fetal heart rate and prevent further decelerations.
Oxygen is a vital nutrient for the fetus, and it is essential for maintaining a normal fetal heart rate.
When the fetal heart rate decelerates, it is a sign that the fetus is not getting enough oxygen.
Applying an oxygen mask to the mother can help to increase the amount of oxygen that is available to the fetus.
Choice D rationale:
The nurse should monitor the client's vital signs and fetal heart rate to assess the client's progress and the well-being of the
fetus.
Vital signs, such as blood pressure, pulse, and respiration rate, can provide important information about the mother's health
and how she is coping with labor.
The fetal heart rate is a direct measure of the fetus's well-being.
By monitoring these parameters, the nurse can identify any potential problems and intervene as needed.
Additional notes:
The nurse should also encourage the client to change positions, as this can help to relieve cord compression.
The nurse should also prepare for the possibility of a rapid delivery, as decelerations in the fetal heart rate can sometimes be a
sign of fetal distress.
Correct Answer is D
Explanation
Choice A rationale:
Placing pillows under the client's knees can actually increase the risk of thrombophlebitis. This is because it flexes the knees,
which can cause blood to pool in the legs. This pooling of blood can lead to the formation of blood clots.
Choice B rationale:
Keeping the client on bed rest is also a risk factor for thrombophlebitis. This is because immobility can cause blood to pool in
the legs. It's important to encourage early and frequent ambulation to promote venous return and prevent clot formation.
Choice C rationale:
Applying warm, moist soaks to the client's lower legs can help to relieve the symptoms of thrombophlebitis, but it does not
prevent it. Warm compresses can help to improve circulation and reduce inflammation, but they're not a preventative
measure.
Choice D rationale:
Encouraging the client to ambulate frequently is the most effective way to prevent thrombophlebitis. This is because it helps to
promote venous return and prevent blood from pooling in the legs. Ambulation also helps to activate the calf muscles, which
act as a natural pump to help move blood back to the heart.
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