ATI MATERNAL-NEWBORN PROCTORED EXAM
(Detail Solutions and Resource for the test)
1. Two hours after delivery the nurse assesses the client and documents that the fundus is soft, boggy, above the level of the umbili
...
ATI MATERNAL-NEWBORN PROCTORED EXAM
(Detail Solutions and Resource for the test)
1. Two hours after delivery the nurse assesses the client and documents that the fundus is soft, boggy, above the level of the umbilicus, and displaced to the right side. The nurse encourages the client to void. Which is the rationale for this nursing action?
Correct: Bladder distention can lead to postpartum hemorrhage. A full bladder displaces the uterus causing it not to contract properly. Emptying the bladder allows the uterus to contract more firmly.
Incorrect: A distended bladder rises out of the abdomen, causing the uterus to be displaced and increasing the risk of hemorrhage. It does not affect the perineum.
Incorrect: Bladder distention can lead to urinary stasis and infection. This, however, does not relate to the soft, boggy uterus or the potential for hemorrhage.
Incorrect: Massaging is uncomfortable regardless of whether the bladder is full or not. A full bladder displaces the uterus causing it not to contract properly, which may lead to postpartum hemorrhage.
A full bladder prevents normal contractions of the uterus.
An overdistended bladder may press against the episiotomy causing dehiscence.
Distention of the bladder can cause urinary stasis and infection.
It makes the client more comfortable when the fundus is massaged.
[Show More]
