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.
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.
You might also like to view...
Which instructions should the nurse provide to a patient taking an antifungal medication?
a. "Do not stop treatment when symptoms disappear." b. "Two weeks of therapy are usually all that is needed." c. "Keep your unused medication for up to 1 year in case you need it again." d. "Thankfully, there are very few side effects to these drugs."
The spiritual domain does not influence the decision to exercise
Indicate whether the statement is true or false
Despite the availability of Children's Health Insurance Programs (CHIPs), the nurse in a pediatric clinic knows that many eligible children are not enrolled. The nursing intervention that can best help eligible children become enrolled is:
1. Assessment of the details of the family's income and expenditures. 2. Case management to limit costly, unnecessary duplication of services. 3. Advocacy for the child by encouraging the family to investigate its CHIP eligibility. 4. Education of the family about the need for keeping regular well-child visit appointments.
The nurse is teaching a class on preventing diaper rash in newborns to a group of new parents. Which statement made by a parent indicates a correct understanding of the teaching?
a. "I should cleanse my infant's skin with a commercial diaper wipe every time I change the diaper." b. "If my infant's buttocks become slightly red, I will expose the skin to air." c. "I should wash my infant's buttocks with soap before applying a thin layer of oil." d. "I will apply baby oil and powder to the creases in my infant's buttocks."