Home » NCLEX » NCLEX-RN » When palpating the uterus, the nurse assesses that it is somewhat soft, 1 fingerbreadth above the umbilicus, and midline. The nursing action to be taken is to:
On the first postpartal day, a client tells the nurse that she has been changing her perineal pads every 1/2 hour because they are saturated with bright red vaginal drainage. When palpating the uterus, the nurse assesses that it is somewhat soft, 1 fingerbreadth above the umbilicus, and midline. The nursing action to be taken is to:
A. Gently massage the uterus until firm, express any clots, and note the amount and character of lochia
B. Catheterize the client and reassess the uterus
C. Begin IV fluids and administer oxytocic medication
D. Administer analgesics as ordered to relieve discomfort
Correct Answer: A
Explanation/Reference:
Explanation:
(A) Gentle massage and expression of clots will let the fundus return to a state of firmness, allowing the uterus to function as the "living ligature." (B) A distended bladder may promote uterine atony; however, after determining the bladder is distended, the nurse would have the client void. Catheterization is only done if normal bladder function has not returned. (C) Oxytocic medications are ordered and administered if the uterus does not remain contracted after gentle massage and determining if the bladder is empty. (D) The client is not complaining of discomfort or pain; therefore, analgesics are not necessary.
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