Maternal / Newborn Question #10

Question

The nurse is performing a BUBBLE LE postpartum assessment and palpates a raised area just above the symphysis pubis. Which is the nurse’s priority action?

Answers

1. Document the finding.
   • Rationale:
2. Massage the uterus.
   • Rationale:
3. Assist the client to void.
   • Rationale:
4. Alert the health care provider.
   • Rationale:

Overview

Explanation

The raised area indicates a full bladder, which may interfere with uterine involution. Having the client to void is an important intervention. Option A is incorrect since it is not the priority action. The nurses intervention is priority and will document intervention and client response afterward. Option B is incorrect since massaging the uterus will not help decrease the raise area. Option D is incorrect as the health care provider does not need notification.

Learning Outcomes

Test Taking Tip

Video Rationale