A nurse is performing fundal massage for a client who has uterine atony and postpartum hemorrhage.
Which of the following actions should the nurse take when performing this procedure?
Use one hand to stabilize the lower uterine segment while massaging the fundus with the other hand
Apply firm pressure on the fundus with both hands until it becomes firm and contracted
Massage the fundus in a circular motion with one hand while supporting the back with the other hand
Rub the fundus vigorously with one hand until it becomes hard and expels clots
The Correct Answer is A
Use one hand to stabilize the lower uterine segment while massaging the fundus with the other hand.
This action prevents the uterus from inverting and reduces the risk of trauma to the cervix and vagina.
The nurse should also monitor the amount and consistency of lochia.
Choice B is wrong because applying firm pressure on the fundus with both hands can cause uterine inversion, which is a life-threatening complication of postpartum hemorrhage.
The nurse should use gentle pressure and avoid overstimulation of the uterus.
Choice C is wrong because massaging the fundus in a circular motion with one hand while supporting the back with the other hand can cause displacement of the uterus and increase bleeding.
The nurse should massage the fundus in a downward motion from the top of the uterus to the umbilicus.
Choice D is wrong because rubbing the fundus vigorously with one hand until it becomes hard and expels clots can cause uterine rupture, which is another serious complication of postpartum hemorrhage.
The nurse should avoid excessive manipulation of the uterus and allow clots to pass naturally.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
All of these conditions are risk factors for postpartum hemorrhage (PPH), which is severe bleeding after childbirth.
Choice A) Prolonged labor is a risk factor for PPH because it can cause uterine fatigue and atony, which is the inability of the uterus to contract and compress the blood vessels.
Choice B) Oligohydramnios is a risk factor for PPH because it can cause placental abruption, which is the premature separation of the
Correct Answer is B
Explanation
This is because a boggy uterus that is displaced to the right of midline indicates that the bladder is full and pushing the uterus out of place.A full bladder can prevent the uterus from contracting effectively after delivery, leading to excessive bleeding and postpartum hemorrhage (PPH).
Emptying the bladder can help the uterus return to its normal position and tone.
Choice A is wrong because applying ice packs to the perineum may help reduce swelling and pain, but it will not address the underlying cause of the boggy uterus.
Choice C is wrong because increasing the rate of IV fluids may worsen the bleeding by diluting the blood and reducing its clotting ability.
Choice D is wrong because administering carboprost, a medication that stimulates uterine contractions, may be indicated if other measures fail to restore uterine tone, but it is not the first action to take.Carboprost also has side effects such as fever, nausea, vomiting, and diarrhea.
Normal ranges for uterine size and position after delivery are:
• Immediately after delivery: at or slightly below the level of the umbilicus (navel)
• 6 hours after delivery: 1 fingerbreadth above the umbilicus
• 12 hours
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.