A nurse is caring for a client who had a vaginal delivery 1 day ago. The nurse determines that the client's fundus is firm, located 2 fingerbreadths above the umbilicus, and deviated to the left. Which of the following actions should the nurse take first?
Monitor perineal pads for clots.
Assist the client to empty her bladder.
Notify the provider.
Administer a prescribed analgesic.
The Correct Answer is B
Choice A rationale
"Monitor perineal pads for clots.”. This is incorrect because while monitoring for clots is important, it does not address the underlying issue causing the fundal deviation.
Choice B rationale
"Assist the client to empty her bladder.”. This is correct because a full bladder can cause the uterus to deviate and impede uterine involution. Emptying the bladder helps the uterus to contract properly and return to its normal position.
Choice C rationale
"Notify the provider.”. This is incorrect because the immediate action should be to address the potential cause of the deviation (a full bladder), which can be managed by the nurse.
Choice D rationale
"Administer a prescribed analgesic.”. This is incorrect because administering pain relief does not address the cause of the fundal deviation and does not alleviate the potential issue.
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Correct Answer is A
Explanation
Choice A rationale
Fundus located to the right of the umbilicus requires intervention. This can indicate a full bladder, which can inhibit uterine contraction and increase the risk of postpartum hemorrhage.
Choice B rationale
A temperature of 37.8° C (100° F) is a common finding postpartum and usually does not require intervention unless it is accompanied by other signs of infection.
Choice C rationale
Deep tendon reflexes 2+ is a normal finding and does not require intervention. It indicates normal neuromuscular function.
Choice D rationale
A moderate amount of lochia rubra is expected postpartum and does not require intervention unless it is excessive or associated with other abnormal symptoms.
Correct Answer is B
Explanation
Choice A rationale
Ensuring the client has a full bladder before the procedure is incorrect. A full bladder can cause discomfort during the pelvic examination and may obscure the pelvic organs, making the examination more challenging for the provider.
Choice B rationale
Instructing the client to bear down when the speculum is inserted is correct. Bearing down helps relax the pelvic muscles, making it easier to insert the speculum and perform the examination with minimal discomfort.
Choice C rationale
Encouraging the client to take rapid, shallow breaths during the procedure is incorrect. This can increase anxiety and tension in the pelvic muscles, making the examination more uncomfortable.
Choice D rationale
Applying povidone-iodine to the provider's fingers prior to bimanual examination is incorrect. The standard procedure involves using gloves and lubricant to prevent infection and ensure patient comfort, not povidone-iodine.