A postpartum client's fundus is firm, 3 cm above the umbilicus, and displaced to the right. Which of the following interventions should the nurse take?
Assist the client to void then reassess the fundus.
Document the findings as within normal limits.
Gently massage the client's fundus.
Encourage the client to ambulate.
The Correct Answer is A
Choice A rationale:
Assisting the client to void is a priority intervention in this situation. A full bladder can displace the uterus and prevent it from contracting effectively, leading to a boggy and high- positioned fundus. After the client empties her bladder, the nurse should reassess the fundus to ensure it has descended to its appropriate location, which is usually at or just below the level of the umbilicus.
Choice B rationale:
Documenting the findings as within normal limits is incorrect because a firm, displaced fundus that is 3 cm above the umbilicus is not considered normal. This finding indicates that the uterus is not contracting adequately, and the nurse should take appropriate actions to address the issue.
Choice C rationale:
Gently massaging the client's fundus is not the correct intervention in this case. Massaging a firm fundus could cause uterine irritation and should be avoided. Instead, the nurse should encourage the client to empty her bladder, which often helps the uterus contract and descend to its proper position.
Choice D rationale:
Encouraging the client to ambulate may be helpful in some cases to promote uterine contractions and involution. However, in this situation, the priority is to address the full bladder, as it is a common cause of a displaced and high fundus shortly after delivery.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
The nurse should discontinue the oxytocin infusion if the client's contraction frequency is every 3 minutes. Frequent contractions may lead to uterine hyperstimulation, which can reduce fetal blood flow and oxygenation, potentially causing fetal distress. Normal contraction frequency during labor is typically every 2 to 5 minutes.
Choice B rationale:
Contraction duration of 100 seconds is not an indication to discontinue the oxytocin infusion. The duration of contractions can vary during labor, and 100 seconds is within the normal range of contraction duration, which is usually 45 to 90 seconds.
Choice C rationale:
Fetal heart rate with moderate variability is not an indication to discontinue the oxytocin infusion. Moderate variability in fetal heart rate is a reassuring sign, indicating a healthy fetal response to labor. It shows that the fetus is tolerating the contractions well and is not experiencing fetal distress.
Choice D rationale:
A fetal heart rate of 118/min is not an indication to discontinue the oxytocin infusion. The normal fetal heart rate range is typically between 110 to 160 beats per minute, and a heart rate of 118/min falls within this normal range. However, if the fetal heart rate deviates significantly from the normal range or shows signs of distress, further assessment and intervention are required.
Correct Answer is A
Explanation
Choice A rationale:
The client's statement, "I will check the identification badge of anyone who removes my baby from our room,” indicates an understanding of newborn safety. This statement shows the client's awareness of the importance of verifying the identity of anyone handling their baby before allowing them to be taken out of the room. Checking identification badges helps ensure that only authorized personnel, such as nurses or hospital staff, are allowed to handle the newborn, reducing the risk of unauthorized individuals taking the baby.
Choice B rationale:
This statement is incorrect and does not demonstrate an understanding of newborn safety. Including a photo of the baby along with public birth announcements to social media can compromise the baby's security and privacy. It may expose sensitive information about the baby's location and identity, making the baby vulnerable to potential risks.
Choice C rationale:
This statement is incorrect as it poses a safety risk to the newborn. Allowing the baby to sleep on the bed when the client is in the shower increases the risk of falls or suffocation. The baby should always be placed in a safe sleep environment, such as a crib or bassinet, to minimize the risk of accidents.
Choice D rationale:
This statement is incorrect and does not reflect an understanding of newborn safety. Nurses should not carry the baby in their arms to the nursery. Instead, they should use a crib or an infant carrier to transport the baby safely.
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