The nurse assesses a boggy uterus with the fundus above the umbilicus and deviated to the side. The nurse should next assess:

Blood pressure

Amount of lochia

Fulness of the bladder

Level of pain

Answer and Explanation

The Correct Answer is C

Fullness of the bladder. A boggy uterus with the fundus above the umbilicus and deviated to the side indicates that the uterus is not contracting properly and may be displaced by a full bladder. A full bladder can interfere with uterine involution and increase the risk of postpartum hemorrhage. The nurse should assess the bladder and assist the patient to empty it if needed.

Choice A. Blood pressure is not the next assessment because it is not related to the position and tone of the uterus. Blood pressure may be affected by blood loss, but it is not a priority in this situation.

Choice B. Amount of lochia is not the next assessment because it is not related to the position and tone of the uterus. Lochia may be increased or decreased depending on the uterine contraction, but it is not a priority in this situation.

Choice D. Level of pain is not the next assessment because it is not related to the position and tone of the uterus. Pain may be present due to uterine cramping or other factors, but it is not a priority in this situation.

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Correct Answer is A

Explanation

Massage the fundus. This is because massaging the fundus (the upper part of the uterus) can help the uterus contract and prevent excessive bleeding after delivery. A soft, boggy uterus indicates uterine atony, which is a failure of the uterus to contract sufficiently after childbirth.

Uterine atony is the most common cause of postpartum hemorrhage, which can be life-threatening if not treated promptly¹².

Choice B is not correct because initiating measures that encourage voiding is not the appropriate intervention for a soft, boggy uterus. A full bladder can interfere with uterine contractions and cause bleeding, so it is important to empty the bladder after delivery. However, this should be done after massaging the fundus.

Choice C is not correct because positioning the patient flat is not the appropriate intervention for a soft, boggy uterus. Positioning the patient flat can increase blood loss and reduce venous return. The patient should be positioned with the head slightly elevated and the legs flexed to improve blood circulation and prevent shock³.

Choice D is not correct because notifying the doctor is not the first intervention for a soft, boggy uterus. Notifying the doctor is important if bleeding persists or worsens despite massaging the fundus. The doctor may order medications or other treatments to stop the bleeding and prevent complications¹.

A. Sucking B. Grasp C. Tonic neck D. Rooting

Correct Answer is D

Explanation

Rooting. The rooting reflex is a primitive neonatal reflex that helps the baby find the breast or bottle to start feeding. When the corner of the baby's mouth is stroked or touched, the baby will turn his or her head and open his or her mouth to follow and root in the direction of the stroking. This reflex lasts about 4 months.

Choice A. Sucking is not the correct answer because it is a different reflex that starts when the roof of the baby's mouth is touched, and it does not help the baby find the breast or bottle.

Choice B. Grasp is not the correct answer because it is a reflex that causes the baby to close his or her fingers in a grasp when the palm of the hand is stroked, and it has nothing to do with breastfeeding.

Choice C. Tonic neck is not the correct answer because it is a reflex that causes the baby to assume a "fencing" position when the head is turned to one side, and it also has nothing to do with breastfeeding.

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The nurse assesses a boggy uterus with the fundus above the umbilicus and deviated to the side. The nurse should next assess:

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Naxlex Comprehensive Predictor Exams

Following delivery, the nurse's assessment reveals a soft, boggy uterus located above the level of the umbilicus. The appropriate intervention is:

Correct Answer is A

Explanation

A first-time mother reports that she is experiencing difficulty breastfeeding her newborn. The neonatal reflex that the nurse would teach the mother to elicit, in order to facilitate breastfeeding is:

Correct Answer is D

Explanation

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