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 A
Explanation
Rationale:
A. Elevating the affected leg is an important intervention for reducing swelling and promoting venous return, which can help alleviate discomfort and prevent further complications.
B. Placing cold compresses on the edematous area may provide temporary relief but is not a standard intervention for deep-vein thrombosis and could potentially harm tissue if applied for too long.
C. Restricting the client to 1 L of fluid per day is inappropriate, as adequate hydration is essential for maintaining good venous health and preventing further complications.
D. Maintaining the client on bed rest is not necessary; while rest is important, early ambulation is encouraged to promote circulation and prevent further clot formation unless contraindicated.
Correct Answer is C
Explanation
Rationale:
A. Comparing the nurse's skills to coworkers may not provide an accurate evaluation as it can vary based on individual roles and responsibilities.
B. While client satisfaction reports can reflect overall performance, they may not specifically address time management skills.
C. Maintaining regular notes about the nurse's time management skills allows for ongoing assessment and provides concrete examples during the appraisal, making it the most effective method.
D. Asking another staff nurse for evaluation can introduce bias and may not provide a comprehensive view of the nurse's time management skills.