Practice Question
A nurse is caring for a client who had a vaginal delivery 2 hr ago. Which of the following actions should the nurse anticipate in the care of this client? (Select all that apply.)
Answer Choices:
Correct Answer:
Massage a firm fundus.
Rationale:
Massage a firm fundus
🟢 Even if the fundus feels firm, gentle massage may be used to maintain uterine tone and encourage continued contraction, particularly in the first hours after delivery.
🟢 This helps prevent uterine atony, a leading cause of postpartum hemorrhage.
🟢 However, over-massaging a firm uterus is avoided unless clinically indicated.
🟢 Regular assessments and light stimulation help support normal involution of the uterus.
Determine whether the fundus is midline
🟢 A midline position of the uterus indicates that the bladder is not distended and that the uterus is well-positioned to contract effectively.
🟢 If the fundus is deviated to the side, it may suggest a full bladder, which can impede uterine contraction and increase bleeding risk.
🟢 Assessing fundal position is a standard step in postpartum assessments.
🟢 It helps determine if additional interventions such as encouraging voiding are necessary.
Document fundal height
🟢 Measuring and documenting fundal height helps monitor uterine involution, or the gradual return of the uterus to its pre-pregnancy size.
🟢 It provides a reference for comparison over time, especially when identifying delayed involution or hemorrhage.
🟢 Accurate documentation ensures continuity of care between shifts and providers.
🟢 Fundal height is typically measured in relation to the umbilicus (e.g., “1 fingerbreadth below the umbilicus”).
Observe the lochia during palpation of fundus
🟢 Lochia is assessed in terms of amount, color, and consistency during and after fundal palpation.
🟢 Increased bleeding during palpation may indicate uterine atony or retained placental fragments.
🟢 Monitoring lochia helps identify early signs of postpartum hemorrhage.
🟢 Nurses should document and report saturation patterns or presence of clots.
Administer methylergonovine maleate if uterus is boggy
🟢 A boggy uterus signals uterine atony, which is a critical cause of excessive postpartum bleeding.
🟢 Methylergonovine (Methergine) is a uterotonic that stimulates sustained uterine contractions.
🟢 It helps firm the uterus and reduce blood loss, especially when initial fundal massage is ineffective.
🟢 Before administering, the nurse must ensure the client's blood pressure is within safe limits, as the medication can elevate BP.
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This question is from RN ATI~Maternal &Newborn final Exam which contains 81 questions.
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Question Details
- Category: RN Nursing Exam(s)
- Subcategory: ATI Exam(s)
- Domain: RN ATI Maternal & Newborn Care
- Answer Choices: 5