Question

On a client's first postpartum day, nursing assessment reveals vital signs within normal limits, a boggy uterus, and saturation of the perineal pad with lochia rubra. Which of the following actions by the nurse is the most appropriate?

1) Administer oxytocin as prescribed.
2) Reassess the client in 2 hours.
3) Massage the uterine fundus gently.
4) Notify the physician or nurse-midwife.

Answer 1

The most appropriate action for a nurse when a postpartum client has a boggy uterus and saturated perineal pad with lochia rubra is to gently massage the uterine fundus to stimulate contractions and reduce bleeding. Option 3.

Step-by-step explanation:

When a client on their first postpartum day has vital signs within normal limits but presents with a boggy uterus and saturation of the perineal pad with lochia rubra, the most appropriate action by the nurse is to massage the uterine fundus gently option 3. A boggy uterus indicates that the uterus is not contracting effectively, which can lead to excessive bleeding. By massaging the fundus, the nurse is stimulating the uterus to contract, which helps to stop the bleeding and encourages the uterus to return to its normal size more quickly. Additionally, the massage can help expel any remaining clots or placental fragments that may be contributing to the bleeding. If massaging the fundus does not yield a firm uterine tone or if the excessive bleeding continues, the nurse should then notify the physician or nurse-midwife. Administering oxytocin may also be prescribed to enhance uterine contractions and reduce bleeding.