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A nurse is assessing a postpartum client who delivered vaginally 2 days ago and notes that her fundus is boggy and displaced to the right side of her abdomen.
Which of the following actions should the nurse take first?
administering oxytocin is not the first action the nurse should take. Oxytocin is a medication that can also help the uterus contract, but it should be given after massaging the fundus and assessing the bleeding.
assisting with ambulation is not appropriate for a client with a boggy and displaced fundus. Ambulation can increase bleeding and cause orthostatic hypotension due to blood loss.
encouraging frequent voiding is not the first action the nurse should take.
A full bladder can displace the uterus and prevent effective contractions, so voiding can help the uterus return to its normal position. However, this should be done after massaging the fundus and assessing the bleeding.
Massage her fundus.
This is because a boggy and displaced fundus indicates uterine atony, which is the failure of the uterus to contract sufficiently after delivery.
This can lead to excessive bleeding and postpartum hemorrhage. Massaging the fundus can help stimulate uterine contractions and reduce blood loss.
The correct answer is choice D. Massage her fundus.
This is because a boggy and displaced fundus indicates uterine atony, which is the failure of the uterus to contract sufficiently after delivery.
This can lead to excessive bleeding and postpartum hemorrhage. Massaging the fundus can help stimulate uterine contractions and reduce blood loss.
Choice A is wrong because administering oxytocin is not the first action the nurse should take. Oxytocin is a medication that can also help the uterus contract, but it should be given after massaging the fundus and assessing the bleeding.
Choice B is wrong because assisting with ambulation is not appropriate for a client with a boggy and displaced fundus. Ambulation can increase bleeding and cause orthostatic hypotension due to blood loss.
Choice C is wrong because encouraging frequent voiding is not the first action the nurse should take.
A full bladder can displace the uterus and prevent effective contractions, so voiding can help the uterus return to its normal position. However, this should be done after massaging the fundus and assessing the bleeding.