NCLEX-RN · Question #616
When assessing the client 6 hours postpartum, the fundus is found to be U +3, displaced to the right of midline, and slightly boggy. The nurse would first:
The correct answer is C. Assess for a full bladder. (A) Oxytocin may not be necessary if the bladder is emptied and if the uterus remains firm, midline, and at about U11 after massage. (B) The same rationale as for answer "A" applies. (C) A full bladder is the most common cause of uterine atony. If the bladder is full, it should…
Question
When assessing the client 6 hours postpartum, the fundus is found to be U +3, displaced to the right of midline, and slightly boggy. The nurse would first:
Options
- AIncrease the IV oxytocin drip rate
- BGive methergine IM
- CAssess for a full bladder
- DGrasp the uterus and massage vigorously
How the community answered
(17 responses)- A6% (1)
- C82% (14)
- D12% (2)
Explanation
(A) Oxytocin may not be necessary if the bladder is emptied and if the uterus remains firm, midline, and at about U11 after massage. (B) The same rationale as for answer "A" applies. (C) A full bladder is the most common cause of uterine atony. If the bladder is full, it should be emptied and the uterus reassessed before further intervention. (D) If the bladder is full, the uterus will not stay contracted or return to a normal position. Overly vigorous massage also encourages uterine atony.
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