Maternal / Newborn Question #16

Question

The nurse is caring for a woman who had an uncomplicated vaginal delivery 3 hours ago. During assessment, the nurse palpates a boggy fundus and the client is urged to void. After voiding 400 mL urine, the nurse reassesses the fundus and finds it is still boggy. Which action will the nurse perform next?

Answers

  1. Contact the health care provider and inform that involution is occurring.
    • Rationale:
  2. Administer buccal pitocin.
    • Rationale:
  3. Massage the fundus until firm.
    • Rationale:
  4. Assess lochia and count the number of pads used.
    • Rationale:

Overview

Explanation

The nurse should gently massage the uterine fundus and reassess. Option A is incorrect since involution is the gradual decrease in uterine size. Boggy fundus should be first evaluated by the nurse prior to contacting a health care provider. Additional pitocin is not indicated and although lochia and pads should be assessed, it should be performed after massage of the fundus since clots may be expelled after massage.

Learning Outcomes

Test Taking Tip

Video Rationale