Question

A nurse is assessing a client who gave birth vaginally 12 hours ago and palpates her uterus to the right above the umbilicus. Which of the following interventions should the nurse perform?

a) Document the findings as normal.

b) Administer pain medication.

c) Assist the client with breastfeeding.

d) Notify the provider of the displaced uterus.

Answer 1

The nurse should notify the provider of the displaced uterus as it may indicate a possible complication, such as a retained placenta. This finding could lead to postpartum hemorrhage and requires immediate attention from the provider.

Step-by-step explanation:

Afterbirth is the final stage of childbirth, which involves the delivery of the placenta and associated membranes. The myometrium continues to contract after the birth of the newborn, which helps shear the placenta from the back of the uterine wall and facilitate its delivery through the vagina. Continued uterine contractions also reduce blood loss from the site of the placenta. If the placenta does not birth spontaneously within approximately 30 minutes, it is considered retained, and the obstetrician may attempt manual removal or perform surgery if necessary.

Based on the information provided, the nurse should notify the provider of the displaced uterus. This finding may indicate a possible complication, such as a retained placenta, which could lead to postpartum hemorrhage. It is important for the provider to be alerted so that appropriate interventions can be implemented.