Question

The nurse assesses a multigravida who is four hours postpartum. Findings include that fundus is firm, 1 centimeter above the umbilicus, and deviated to the right side. The lochia is moderately heavy and bright red. Which nursing intervention has priority?

1. Massage the fundus.
2. Administer intravenous oxytocin.
3. Document these normal findings.
4. Assist the client up to void.

Answer 1

The priority nursing intervention is to massage the fundus(option 1) to stimulate contractions and prevent excessive bleeding.

Step-by-step explanation:

The priority nursing intervention in this case would be to Massage the fundus (option 1). The findings indicate that the uterus is deviated to the right side, which suggests a possible uterine atony or lack of strong contractions. Massage of the fundus helps to stimulate contractions and prevent excessive bleeding. Although administering intravenous oxytocin (option 2) can also help promote uterine contractions, it is not the priority intervention in this scenario. Documenting the findings (option 3) is important but not the priority at this moment. Assisting the client up to void (option 4) is a routine postpartum care measure but can be done after addressing the priority intervention.