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.

Answer and Explanation

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.

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Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"}}

Explanation

White blood cell count: Expected—mild leukocytosis is normal postpartum due to physiological stress.
Blood clot size: Expected—small clots, like a pea-sized clot, are common and not concerning unless excessive bleeding occurs.
Uterine findings: Expected—firm and midline uterus indicating effective involution.
Lochia findings: Expected—progressing normally without signs of infection (no foul odor).
Calf findings: Expected—a single varicose vein without tenderness or swelling is not concerning.
Blood pressure: Expected—within normal postpartum range.

A. Express small amounts of milk from the breasts to relieve the pressure. B. Wearing a loose-fitting bra to prevent nipple irritation. C. Apply cold packs to the breasts for comfort. D. Run warm water on her breasts during a shower.

Correct Answer is C

Explanation

Choice A rationale

Expressing milk when bottle-feeding can stimulate further milk production, which would exacerbate the engorgement and discomfort. The goal is to discourage milk production.

Choice B rationale

While a supportive bra is generally recommended for comfort, a loose-fitting bra might not provide adequate support to reduce swelling and discomfort associated with engorgement. A firm, supportive bra is usually advised.

Choice C rationale

Cold packs cause vasoconstriction, which helps to reduce blood flow to the breasts, thereby decreasing swelling, inflammation, and pain associated with engorgement. This provides symptomatic relief without stimulating milk production.

Choice D rationale

Warm water can stimulate milk flow, which is counterproductive when trying to suppress lactation in a bottle-feeding mother experiencing engorgement. Warmth increases blood flow and can worsen swelling and discomfort.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a 32-year-old female client who is 2 days postpartum in the postpartum unit. Exhibits For each potential client finding, click to specify if the finding is expected or unexpected.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"}}

Explanation

A woman gave birth 48 hours ago to a healthy infant girl.She has decided to bottle feed.During the assessment, the nurse notices that both breasts are swollen, warm, and tender on palpation.Which guidance should the nurse provide to the client at this time?

Correct Answer is C

Explanation

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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?