The nurse is in the postpartum unit assessing a client who gave birth 2 hours ago. The nurse notes that the client's fundus is soft and boggy. Her perineal pads have been changed twice over the past 2 hours. What is the initial action of the nurse?
The nurse is in the postpartum unit assessing a client who gave birth 2 hours ago. The nurse notes that the client's fundus is soft and boggy. Her perineal pads have been changed twice over the past 2 hours. What is the initial action of the nurse?
A. Apply pressure on the fundus.
[3%]
B. Massage the fundus until it is firm.
[83%]
C. Notify the physician.
[13%]
D. Elevate the client’s legs.
[1%]
Statistics
Subject/Lesson
Subject
Maternal & Newborn Health
Lesson
Postpartum
Client Need
Test Plan
Health Promotion and Maintenance
Related Topic
Ante/Intra/Postpartum and Newborn Care
Item Type
Item Type
Application
Explanation
Choice B is correct. The initial action of the nurse when she finds that the fundus is soft and boggy is to massage it until it is firm. Massaging the fundus stimulates it to contract and expels blood clots. The goal is to make the fundus firm, which is essential for preventing postpartum hemorrhage.
Choice A is incorrect. Applying pressure on the fundus that is not contracting can lead to an inversion of the uterus and result in massive hemorrhaging. Applying pressure on the fundus may be necessary if massaging alone does not result in firmness but it is not the initial action.
Choice C is incorrect. Notifying the physician is an inappropriate action. The nurse should implement nursing interventions first before informing the physician.
Choice D is incorrect. Elevating the client’s legs can help in shunting blood from the extremities to the vital organs. However, it does not help in managing uterine atony in this client.
Related Videos
3 Key Topics
Postpartum Hemorrhage
30.5 Postpartum Complications & Mental Health
Additional Info
✓ While massaging the fundus, assess the client's vaginal bleeding. Excessive bleeding may indicate postpartum hemorrhage, which requires immediate attention.
✓ In some cases, if uterine atony persists, the healthcare provider may order the administration of oxytocin, a medication that helps stimulate uterine contractions.
✓ Emotional support is crucial during this time. Ensure the client is comfortable, well-informed about the situation, and encouraged to ask questions or express concerns.
