A client delivered a term infant 1 hour ago. Her uterus on assessment is boggy and is U +1 in contrast to the previous assessment of U _2. The immediate nursing response is to:

Question

Options

• AAdminister methergine IM
• BRemove the retained placental fragments
• CAssist the client to the bathroom and provide cues to stimulate urination
• DMassage the fundus until firm

• A
  3% (1)
• B
  8% (3)
• C
  17% (6)
• D
  72% (26)

Explanation

(A) Methergine is given following placental delivery to promote uterine contractions and prevent hemorrhage. Methergine may be administered in this clinical situation, but fundal massage would be thefirst response. (B) Removal of retained placental fragments is done by the physician and is not the first (C) If the fundus rises and is deviated, particularly to theright, the nurse should suspect bladder distention secondary to bladder and urethral trauma associated with birth and decreased bladder tone following delivery. Therefore, women have a diminished sensation to void. (D) A boggy fundus rises and is indicative of blood pooling, predisposing the woman to clot formation. Massage the uterus until firm. Too vigorous massage will result in atonia. Clots may be expelled by a kneading motion of the uterus by the nurse.

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