A nurse is preparing to perform a fundal massage for a postpartum client who is experiencing uterine atony. In which order should the nurse plan to perform the following actions?

Ask the client to lie on her back and with her knees ﬂexed.

Position one hand around the top of the client's fundus and one hand just above the client's symphysis pubis.

Rotate the upper hand to massage the client's uterus while using slight downward pressure to compress the fundus.

Observe the client's perineum for the passage of clots and the amount of bleeding.

Answer and Explanation

The Correct Answer is A, B, C, D

The correct answer is A, B, C, D.

The nurse should plan to perform the following actions in this order:
A.   Ask the client to lie on her back and with her knees ﬂexed.
B.   Position one hand around the top of the client’s fundus and one hand just above the client’s symphysis pubis.
C.   Rotate the upper hand to massage the client’s uterus while using slight downward pressure to compress the fundus.
D.   Observe the client’s perineum for the passage of clots and the amount of
bleeding.
Fundal massage is performed to stimulate uterine contractions and prevent
postpartum hemorrhage.

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Correct Answer is ["A","E"]

Explanation

The nurse should plan to immunize the client with the inactivated inﬂuenza vaccine (A) and the diphtheria-acellular pertussis vaccine (E).

The Centers for Disease Control and Prevention (CDC) recommends that pregnant women get two vaccines during every pregnancy: the inactivated ﬂu vaccine and the Tdap vaccine.

The other vaccines listed are not recommended during pregnancy:

The human papillomavirus vaccine is not recommended during pregnancy.
The varicella vaccine is not recommended during pregnancy.
The measles, mumps, and rubella vaccine is not recommended during pregnancy.

A. "Apply ice packs to your breasts using a 15 minutes on, 45 minutes oﬀ schedule.” B. "Shower daily, allowing warm water to run directly over your breasts.” C. "Wear a loose-fitting nonbinding bra for 72 hours.” D. "Pump your breasts twice daily to relieve discomfort from engorgement.”

Correct Answer is A

Explanation

“Apply ice packs to your breasts using a 15 minutes on, 45 minutes oﬀ schedule.”

This can help reduce swelling and relieve discomfort from engorgement.

Choice B is incorrect because warm water can increase blood ﬂow and may worsen engorgement.

Choice C is incorrect because a supportive bra can help reduce discomfort from engorgement.

Choice D is incorrect because pumping can stimulate milk production and may worsen engorgement.

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A nurse is preparing to perform a fundal massage for a postpartum client who is experiencing uterine atony. In which order should the nurse plan to perform the following actions?

Nursing Test Bank

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