The nurse is providing care to a patient who delivered a 3525-g ...

[Alainaaa8]

The nurse is providing care to a patient who delivered a 3525-g infant 14 hours ago. The nurse palpates the fundus of the uterus as firm and at the umbilicus. What is the nurse's priority action related to this finding?
 
  a. Inform the health care provider.
  b. Encourage the patient to urinate.
  c. Massage the uterus to expel clots.
  d. Document the finding in the patient's chart.

Question 2

Which assessment finding 24 hours after vaginal birth would indicate a need for further intervention?
 
  a. Pain level 5 on scale of 0 to 10
  b. Saturated pad over a 2-hour period
  c. Urinary output of 500 mL in one voiding
  d. Uterine fundus 2 cm above the umbilicus

[jliusyl]

Answer to Question 1

ANS: D
The location of the uterine fundus helps determine whether involution is progressing normally. Immediately after birth, the uterus is about the size of a large grapefruit or softball and weighs approximately 1000 g (2.2 lb). The fundus can be palpated midway between the symphysis pubis and umbilicus in the midline of the abdomen. Within 12 hours, the fundus rises to approximately the level of the umbilicus. This finding is expected and can be followed with documentation. No further action is needed.

Answer to Question 2

ANS: D
By the second postpartum day, the fundus descends by approximately 1 cm/day and should be 1 cm below the umbilicus; pain level of 5, saturated pad over a 2-hour time period, and urinary output of 500 mL in one voiding are normal findings in the postpartum client.

[Alainaaa8]

TYSM

[Viet Thy]

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