The nurse assessing a postpartum client's fundus finds it firm, 2 centimeters above the umbilicus and displaced to the right.
What is the most appropriate nursing intervention at this time?
Have the client void and reassess the fundus.
Start a pad count.
Massage the fundus until firm.
Notify the healthcare provider.
The Correct Answer is A
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Methylergonovine is an oxytocic medication that stimulates smooth muscle contraction of the uterus. While it can cause vasoconstriction and potentially lead to an increase in blood pressure, this is a potential side effect, not the intended therapeutic effect indicating the medication's effectiveness in the postpartum period. The primary goal is uterine contraction to control postpartum bleeding.
Choice B rationale
Breast pain is related to engorgement and milk production, not directly influenced by methylergonovine's action on the uterus. The medication's effectiveness is assessed by its impact on uterine tone and bleeding, not breast comfort. Therefore, the absence of breast pain does not indicate that the methylergonovine has been effective.
Choice C rationale
Methylergonovine is given to decrease postpartum bleeding by promoting uterine contraction, which helps to compress the blood vessels at the placental site. An increase in lochia (postpartum vaginal discharge) would suggest that the medication is not effective in achieving its intended therapeutic outcome of reducing hemorrhage.
Choice D rationale
Methylergonovine's primary therapeutic effect in the postpartum period is to stimulate uterine smooth muscle contraction, leading to a firm fundus. A firm fundus indicates that the uterus is contracting effectively, which helps to compress blood vessels at the placental site and control postpartum bleeding. This is the desired outcome of methylergonovine administration.
Correct Answer is ["B","F","G"]
Explanation
Choice B rationale
Prostaglandin administration, either vaginally or orally, helps to ripen the cervix by increasing collagenase activity and water content, leading to cervical softening, thinning (effacement), and dilation, which are necessary for labor to begin.
Choice F rationale
Amniotomy, or artificial rupture of membranes (AROM), involves the deliberate rupture of the amniotic sac. This can stimulate labor by releasing prostaglandins, increasing uterine contractility, and allowing the presenting part of the fetus to descend further into the pelvis, putting pressure on the cervix.
Choice G rationale
Oxytocin is a synthetic hormone that mimics the action of endogenous oxytocin, stimulating uterine contractions. It is commonly administered intravenously to initiate or augment labor once cervical ripening has occurred or the cervix is favorable.
Choice A rationale
Epidural anesthesia is a method of pain relief during labor, not a method for inducing labor. It provides regional analgesia by blocking nerve impulses in the lower body.
Choice C rationale
Bed rest is generally not recommended for labor induction and can even be counterproductive. Ambulation and positional changes can help to encourage fetal descent and uterine activity.
Choice D rationale
Vitamin supplementation is important for overall maternal and fetal health during pregnancy but does not directly stimulate uterine contractions or cervical changes necessary for labor induction.
Choice E rationale
Fetal ultrasound is used to assess fetal well-being, presentation, and amniotic fluid volume but does not initiate the process of labor induction. .
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