章节:Postpartal Care

SC
正确指数:80% 正确的次数:4 错误的次数:1 4770---Twelve hours after a vaginal birth with epidural anesthesia, the nurse palpates the fundus of a primiparous client and finds it to be firm, above the umbilicus, and deviated to the right. What should the nurse do next?

Saunders Comprehensive Review for the NCLEX-RN® Examination, 7e (Saunders Comprehensive Review for Nclex-Rn)

1. Document this as a normal finding in the client’s record.
2. Contact the healthcare provider (HCP) for a prescription for oxytocin.
3. Encourage the client to ambulate to the bathroom and void.
4. Gently massage the fundus to expel the clots.

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正确答案:
3. Encourage the client to ambulate to the bathroom and void.
解释 :
At 12 hours postpartum, the fundus normally should be in the midline and at the level of the umbilicus. When the fundus is firm yet above the umbilicus, and deviated to the right rather than in the midline, the client’s bladder is most likely distended. The client should be encouraged to ambulate to the bathroom and attempt to void because a full bladder can prevent normal involution. A firm but deviated fundus above the level of the umbilicus is not a normal finding, and if voiding does not return it to midline, it should be reported to the HCP . Oxytocin is used to treat uterine atony. This client’s fundus is firm, not boggy or soft, which would suggest atony. Gentle massage is not necessary because there is no evidence of atony or clots.