A nurse is preparing to assess the uterine fundus of a client in the immediate postpartum period.
When the nurse locates the fundus, she notes that the uterus feels soft and boggy at midline.
Which of the following nursing interventions would be most appropriate initially?
Elevate the mother's legs.
Massage the fundus until it is firm.
Encourage the mother to void.
Push on the uterus to assist in expressing clots.
The Correct Answer is B
Choice A rationale
Elevating the mother's legs may help with venous return and circulation, but it does not directly address a soft and boggy uterus, which indicates uterine atony and a risk for hemorrhage. The immediate priority is to promote uterine contraction.
Choice B rationale
A soft and boggy uterus indicates uterine atony, a primary cause of postpartum hemorrhage. Massaging the fundus stimulates the uterine muscles to contract, which helps to compress the blood vessels at the placental site and reduce bleeding. This is the most appropriate initial intervention to address uterine atony.
Choice C rationale
Encouraging the mother to void is important in the postpartum period as a full bladder can displace the uterus and interfere with its ability to contract. However, in the presence of a soft and boggy uterus, the immediate priority is to directly stimulate uterine contraction through fundal massage before addressing bladder emptying.
Choice D rationale
Pushing on the uterus to express clots without first ensuring the uterus is firm is contraindicated. A soft, atonic uterus is more susceptible to inversion if pressure is applied. Fundal massage should be performed first to encourage uterine contraction and firmness before attempting to express any clots.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
A firm fundus displaced to the right and above the umbilicus often indicates a full bladder. The bladder, when distended, can push the uterus out of its midline position and interfere with its ability to contract effectively, potentially leading to increased bleeding. Having the client void will relieve the pressure on the uterus, allowing it to return to its midline position and remain firm.
Choice B rationale
Starting a pad count is a useful way to quantify the amount of lochia, but it does not address the immediate issue of the displaced fundus and potential bladder distention. It would be a subsequent step to monitor the bleeding after addressing the fundal position.
Choice C rationale
While fundal massage is appropriate for a soft or boggy uterus, the assessment indicates the fundus is already firm. Massaging a firm uterus is not the priority and will not address the displacement caused by a likely full bladder.
Choice D rationale
Notifying the healthcare provider is necessary if the fundus remains displaced and elevated after the client voids, as this could indicate other complications. However, the initial action should be to address the most likely cause, which is bladder distention.
Correct Answer is A
Explanation
Choice A rationale
G represents gravida, the total number of pregnancies, including the current one (2). T represents term births, the number of pregnancies delivered at 37 weeks gestation or later (1). P represents preterm births, the number of pregnancies delivered between 20 and 36 weeks gestation (0). A represents abortions, the number of pregnancies ending before 20 weeks gestation (0). L represents living children (1).
Choice B rationale
This option incorrectly states L as 2. The client has one living child from the previous pregnancy.
Choice C rationale
This option incorrectly states P as 1. The client's previous pregnancy was delivered at 38 weeks, which is considered a term birth, not preterm.
Choice D rationale
This option incorrectly states G as 3. The client is currently pregnant with twins, making this her second pregnancy in total.
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