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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A rationale

A reactive nonstress test demonstrates at least two accelerations in fetal heart rate, defined as an increase of 15 beats per minute above the baseline lasting for 15 seconds, within a 20-minute period. These accelerations indicate adequate fetal oxygenation and a healthy fetal autonomic nervous system response to movement.

Choice B rationale

Drawing blood to evaluate the baby's risk of genetic problems is typically performed through procedures like amniocentesis or chorionic villus sampling, not during a nonstress test. A nonstress test assesses fetal well-being based on heart rate patterns in response to fetal movement.

Choice C rationale

While fetal movement is an indicator of fetal well-being, the nonstress test specifically evaluates the fetal heart rate response to that movement. The number of movements within a specific time frame is a component of a biophysical profile, not the sole indicator in a nonstress test.

Choice D rationale

Ultrasound is used to visualize fetal anatomy and assess for congenital anomalies, which is a component of a fetal anatomy scan typically performed around 18-20 weeks of gestation. A nonstress test primarily monitors fetal heart rate and its reactivity.

A. Have the client void and reassess the fundus. B. Start a pad count. C. Massage the fundus until firm. D. Notify the healthcare provider.

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.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is A

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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?