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anr17 anr17
wrote...
Posts: 1064
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6 years ago
The nurse is caring for a woman who is gravida 2, para 1 on her first postpartum day.
 
  The assessment reveals: temperature 38 C (100 F), pulse 60 beats/minute, blood pressure 118/80 mm Hg, fundus firm at the level of umbilicus and displaced slightly to right, last void 6 hours earlier, moderate amount of lochia rubra, and perineum slightly edematous with episiotomy edges well approximated. The first nursing action should be to:
  a. Notify the nurse-midwife of her temperature.
  b. Apply an ice pack to her perineum.
  c. Assist her to the bathroom to void.
  d. Chart the assessment findings as normal.
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Replies
wrote...
6 years ago
ANS: C
Uterine displacement is usually associated with bladder distention. After the nurse takes her to the bathroom to void, the uterus should shift to a midline position. The other findings are normal.
anr17 Author
wrote...
6 years ago
Excellent response
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