A nurse is caring for a client who is postpartum.



Which of the following findings is an indication for the nurse to administer Rho(D) immune globulin?

Choice A rationale:

Placing the mother in Trendelenburg's position would not correct the uterine displacement. Trendelenburg's position involves

lowering the head of the bed and raising the feet, which can actually worsen uterine displacement by increasing pressure on

the uterus from the abdominal organs.

It is not indicated for uterine displacement and could potentially have adverse effects on the patient's hemodynamic status

and respiratory function.

Choice C rationale:

Notifying the physician is important, but it is not the first action the nurse should take.

The nurse should assess the patient and attempt to correct the displacement before notifying the physician.

Choice D rationale:

Recording the findings is important for documentation, but it is not an intervention that will correct the uterine displacement.

Choice B rationale:

Massaging the fundus is the correct action to take when a postpartum uterus is displaced.

The fundus is the top of the uterus, and massaging it can help to stimulate the uterine muscles to contract and return to their

normal position.

This is often effective in correcting mild to moderate uterine displacements.

Here are the steps involved in massaging the fundus:

Locate the fundus: The nurse should first locate the fundus by palpating the abdomen just below the umbilicus.

Apply gentle pressure: Once the fundus is located, the nurse should apply gentle pressure with the fingertips in a circular

motion.

Continue massaging: The massage should be continued for several minutes, or until the uterus is felt to be firm and in the

midline position.

Additional notes:

If the uterine displacement is severe, or if the patient is experiencing pain or bleeding, the nurse should notify the physician

immediately.

Other interventions that may be used to correct uterine displacement include:

Assisting the patient to empty her bladder

Straight catheterization

Administration of oxytocin to stimulate uterine contractions

Choice A rationale:

Oxygen administration is not indicated in this situation. The client's vital signs are stable, and there is no evidence of

respiratory distress.

Oxygen administration could potentially mask signs of postpartum hemorrhage, which is a serious complication.

It is important to assess the client's respiratory status closely, but oxygen should not be administered unless there is a clear

indication for it.

Choice B rationale:

Methylergonovine is a medication that is used to treat postpartum hemorrhage.

It works by contracting the uterus and reducing blood flow.

However, it is a potent medication that can have serious side effects, such as hypertension and seizures.

It is important to clarify the order with the provider before administering this medication.

The provider may want to assess the client further or consider other options before ordering methylergonovine.

Choice C rationale:

Inserting a urinary catheter is not necessary in this situation.

The client is not experiencing any urinary problems, and there is no evidence of bladder distention.

Catheterization can increase the risk of urinary tract infection, so it should only be performed when there is a clear indication

for it.

Choice D rationale:

Increasing the infusion rate of the IV fluid may be helpful in some cases of postpartum hemorrhage.

However, it is important to assess the client's fluid status before increasing the infusion rate.

Too much fluid can lead to pulmonary edema, which is a serious complication.