The nurse working in the maternity ward is caring for a 24-hour post-partum client. When assessing the client, the nurse notes that her fundus is firm at the level of the umbilicus and is veering a little bit to the right. The initial action for the nurse is to:
The nurse working in the maternity ward is caring for a 24-hour post-partum client. When assessing the client, the nurse notes that her fundus is firm at the level of the umbilicus and is veering a little bit to the right. The initial action for the nurse is to:
A. Check for bladder distention
[83%]
B. Check the client’s blood pressure
[4%]
C. Check if the client has been given oxytocin
[3%]
D. Check the pad count
[9%]
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
Analysis
Explanation
Choice A is correct. A displaced fundus is an indication of a distended bladder. The nurse should assess the client for bladder distention and encourage the client to empty her bladder.
Choice B is incorrect. The nurse can check the client’s blood pressure; however, this action is unrelated to the situation.
Choice C is incorrect. The nurse has assessed that the client’s fundus is firm. Thus, the nurse does not need to check if oxytocin was given.
Choice D is incorrect. The nurse does not need to check the client’s pad count as the client is not showing any signs of uterine atony.
