The nurse is caring for a client who delivered 6 hours ago.
The client’s uterus is boggy and is displaced above and to the right of the umbilicus. What action should the nurse take?
Monitor the client’s vital signs.
Notify the healthcare provider.
Inspect the perineal pad.
Encourage the client to void.
The Correct Answer is D
Choice A rationale
While monitoring the client’s vital signs is an important part of postpartum care, it would not directly address the issue of a boggy uterus that is displaced above and to the right of the umbilicus.
Choice B rationale
Notifying the healthcare provider is important, but it would not be the first action to take. The nurse should first attempt to address the issue.
Choice C rationale
Inspecting the perineal pad could provide information about the client’s postpartum bleeding, but it would not directly address the issue of a boggy uterus that is displaced above and to the right of the umbilicus.
Choice D rationale
Encouraging the client to void is the correct action. A full bladder can displace the uterus, preventing it from contracting properly. By emptying the bladder, the uterus may be able to contract and return to its normal position.
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Related Questions
Correct Answer is D
Explanation
Choice A rationale
Pumping breasts every few hours can stimulate milk production, which is not the goal for a formula-feeding mother.
Choice B rationale
Latching the baby on to feed for just a few minutes can also stimulate milk production, which is not the goal for a formula-feeding mother.
Choice C rationale
Changing breast pads often is a good practice for breastfeeding mothers to maintain hygiene and prevent infections, but it does not directly address the issue of painful, hard, and full breasts in a formula-feeding mother.
Choice D rationale
Wearing a form-fitting bra for the next couple of days can provide support and help reduce the discomfort associated with engorgement in a formula-feeding mother.
Correct Answer is D
Explanation
Choice A rationale
While pushing is a part of labor, reminding the woman to push three times with each contraction is not the primary focus of nursing care during the transitional phase of labor.
Choice B rationale
Assessing the strength of uterine contractions is important, but it is not the primary focus during the transitional phase of labor.
Choice C rationale
Re-evaluating the need for medication is not the primary focus during the transitional phase of labor for a client who anticipates an unmedicated delivery.
Choice D rationale
Assisting the woman to maintain control is the primary focus of nursing care during the transitional phase of labor. This includes providing supportive care and encouragement in dealing with transitional contractions.
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