Ati lpn ob maternal newborn
Ati lpn ob maternal newborn ( 28 Questions)
A nurse is collecting data from a client who is 3 hr postpartum.The nurse notes that the client’s fundus is displaced to the right of midline, is firm, and is two fingerbreadths above the umbilicus.Which of the following actions should the nurse take?
Inserting a urinary catheter is not the first action to take when the fundus is displaced to the right of midline. The displacement is often due to a full bladder, and the client should be encouraged to void first.
Massaging the fundus is appropriate if the uterus is boggy, but in this case, the fundus is firm. The displacement is likely due to a full bladder.
Having the client urinate is the correct action. A full bladder can displace the uterus and prevent it from contracting properly, which can lead to postpartum hemorrhage.
Administering analgesia is not relevant to the issue of a displaced fundus. The priority is to address the cause of the displacement, which is likely a full bladder.
Choice A rationale
Inserting a urinary catheter is not the first action to take when the fundus is displaced to the right of midline. The displacement is often due to a full bladder, and the client should be encouraged to void first.
Choice B rationale
Massaging the fundus is appropriate if the uterus is boggy, but in this case, the fundus is firm. The displacement is likely due to a full bladder.
Choice C rationale
Having the client urinate is the correct action. A full bladder can displace the uterus and prevent it from contracting properly, which can lead to postpartum hemorrhage.
Choice D rationale
Administering analgesia is not relevant to the issue of a displaced fundus. The priority is to address the cause of the displacement, which is likely a full bladder.