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. Hypotension is not a common adverse effect of estradiol; instead, it may cause hypertension.
B. Bruising can indicate thrombocytopenia or other clotting issues, which are serious adverse effects of estradiol and should be reported immediately.
C. Headaches are a common side effect of estradiol but are usually not severe; they typically do not require reporting unless they are persistent or severe.
D. Oliguria is not a known adverse effect of estradiol and may indicate other underlying issues that are unrelated to this medication.
Correct Answer is C
Explanation
Rationale:
A. Applying a cold compress is not recommended for DVT; instead, heat may be more appropriate to alleviate discomfort and improve circulation.
B. Massaging the affected extremity is contraindicated as it can dislodge the clot and lead to complications such as pulmonary embolism.
C. Instructing the client to elevate the affected extremity helps reduce swelling and promote venous return, making it the best action.
D. Assessing pulses proximal to the affected area is important for monitoring circulation, but it is not the primary intervention for managing DVT.