The nurse is preparing to perform a fundal assessment on a ...

[Haya94]

The nurse is preparing to perform a fundal assessment on a postpartum client. The nurse understands that the initial nursing action when performing this assessment is which of the fol-lowing?
 
  1. Ask the client to turn on her side.
  2. Ask the client to urinate and empty her bladder.
  3. Ask the client to lie flat on her back, with her knees and legs flat and straight.
  4. Massage the fundus gently prior to determining the level of the fundus.

Question 2

The nurse understands that the most significant rationale for the application of heat to an area of contusion 72 hours after the injury is to:
 
  1. Prevent abscess formation.
  2. Promote muscle relaxation.
  3. Reabsorb blood from the injured tissue.
  4. Reduce the likelihood of strain as a complication.

[cassie_ragen]

Answer to Question 1

2

Rationale: Before fundal assessment is started, the nurse should ask the mother to empty her bladder so that an accurate assessment can be done. The nurse can then assess the bladder for complete emptying and accurately assess uterine involution. When performing fundal assessment, the woman is asked to lie flat on her back, with the knees flexed. Massaging the fundus is not appropriate unless the fundus is boggy or soft, and then it should be massaged gently until firm.

Answer to Question 2

3

Rationale: The primary benefit from applying heat to a contusion is to speed up the rate of absorption of blood that has hemorrhaged into the affected soft tissue. Although heat also promotes muscle relaxation, this is not the intended benefit of this therapy in treating a contusion. Heat is not applied to reduce abscess formation or prevent muscle strain.

[Haya94]

Excellent

[kthug]

TYSM