A nurse is caring for a client who is postpartum and finds the fundus firm and deviated to the left, lochia is rubra and scant. Based on these findings, which of the following actions should the nurse take?
Ask the client to rate her pain.
Encourage the client to perform Kegel exercises.
Assist the client to the bathroom to void.
Encourage the client to move to the left lateral position.
The Correct Answer is C
Choice A rationale
Asking the client to rate her pain is important for assessing discomfort, but it does not address the immediate issue of a deviated fundus. A deviated fundus often indicates a full bladder, which can impede uterine contraction and increase the risk of postpartum hemorrhage.
Choice B rationale
Encouraging the client to perform Kegel exercises is beneficial for pelvic floor strengthening but does not address the immediate concern of a deviated fundus. The priority is to ensure the uterus can contract properly.
Choice C rationale
Assisting the client to the bathroom to void is the correct action. A full bladder can displace the uterus, preventing it from contracting effectively and increasing the risk of hemorrhage. Voiding helps the uterus return to its proper position and function.
Choice D rationale
Encouraging the client to move to the left lateral position may provide comfort but does not address the underlying issue of a full bladder causing uterine displacement.
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Correct Answer is ["A","B","C","D"]
Explanation
Choice A rationale
Warm compresses can help to reduce perineal pain and swelling by increasing blood flow to the area, which promotes healing and provides comfort. The warmth can also help to relax the muscles and reduce discomfort.
Choice B rationale
Tucks pads, which contain witch hazel, are effective in reducing perineal pain and swelling. Witch hazel has anti-inflammatory and astringent properties that help to soothe irritated skin and reduce swelling, providing relief from discomfort.
Choice C rationale
Dermaplast spray is a topical anesthetic that provides temporary relief from perineal pain. It contains benzocaine, which numbs the area and reduces pain. It also has antiseptic properties that help to prevent infection in the perineal area.
Choice D rationale
Ibuprofen 600 mg PO is a nonsteroidal anti-inflammatory drug (NSAID) that helps to reduce pain and inflammation. It works by inhibiting the production of prostaglandins, which are chemicals that cause inflammation and pain. Taking ibuprofen can provide significant relief from perineal discomfort.
Choice E rationale
Encouraging the patient to sit in a high Fowler’s position is not recommended for perineal pain management. This position can increase pressure on the perineum, potentially worsening the pain and discomfort.
Correct Answer is C
Explanation
Choice A rationale
A temperature of 99.0°F (37.3°C) is within the normal range and is not specifically associated with cardiovascular system changes in the postpartum period. It is a common finding and does not indicate any specific cardiovascular changes.
Choice B rationale
A respiratory rate of 18/min is within the normal range for adults and is not specifically associated with cardiovascular system changes in the postpartum period. It is a common finding and does not indicate any specific cardiovascular changes.
Choice C rationale
An elevated white blood cell (WBC) count of 22,000/mm³ is a common finding in the postpartum period due to the body’s response to the stress of childbirth. This leukocytosis is a normal physiological response and is associated with the cardiovascular system changes during this period.
Choice D rationale
Urinary retention is not specifically associated with cardiovascular system changes in the postpartum period. It can occur due to various reasons, including the effects of anesthesia or trauma during delivery, but it is not a direct result of cardiovascular changes.