A nurse is caring for a client who had a vaginal delivery 2 hours ago. Which of the following actions should the nurse anticipate in the care of this client? (Select all that apply.)
Administer methylergonovine maleate if the uterus is boggy
Massage a firm fundus.
Document fundal height.
Observe the lochia during palpation of the fundus
Determine whether the fundus is midline.
Correct Answer : A,C,D,E
Rationale:
A. Administering methylergonovine maleate is indicated if the uterus is boggy (atonic), as it helps to contract the uterus and reduce the risk of postpartum hemorrhage.
B. Massaging a firm fundus is not appropriate; instead, the nurse should massage a boggy (soft) fundus to promote uterine contraction.
C. Documenting fundal height is a necessary action to assess uterine involution and ensure it is progressing as expected after delivery.
D. Observing the lochia during palpation of the fundus is important to assess for any abnormal findings, such as heavy bleeding, which could indicate complications.
E. Determining whether the fundus is midline is crucial; a displaced fundus may indicate bladder distention, which can affect uterine contraction.
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Correct Answer is B
Explanation
Rationale:
A. Attaching the NG tube to low intermittent suction is not recommended during gastric lavage, as suctioning can remove the lavage solution before it has a chance to work effectively.
B. Instilling the lavage solution in volumes of 500 mL at a time is correct as it allows for effective cleansing of the stomach and can help to clear out any blood or debris present.
C. Chilled lavage solution should not be used; it is recommended to use room temperature or warmed solution to avoid discomfort and potential complications such as cramping.
D. While 0.9% sodium chloride is isotonic and can be used for irrigation, it is not typically the solution used for gastric lavage; water or a specific lavage solution is more appropriate.
Correct Answer is C
Explanation
Rationale:
A. Diarrhea is not a typical manifestation of ovarian cancer and may be more related to gastrointestinal issues.
B. Urinary retention can occur but is not a common initial symptom associated with ovarian cancer.
C. Abdominal bloating is a common symptom associated with ovarian cancer and should be included in the educational session. It may occur due to fluid accumulation or tumor growth.
D. Purulent discharge is not a typical manifestation of ovarian cancer and may suggest an infection rather than a cancer diagnosis.