QUESTION: "During the immediate postpartum period after delivering twins, the client experiences uterine atony. Which of the following should the nurse do first?"
CHOICES
( O ) a.) Gently massage the fundus.
( X ) b.) Assess the client for infection.
( X ) c.) Determine if the uterus has ruptured.
( X ) d.) Increase the intravenous fluid rate.
RATIONALE: Uterine atony means that the uterus is not firm because it is not contracting. First, the nurse should gently massage the uterus in an effort to help contract the uterus and make it firm. Clients with multiple gestation, polyhydramnios, prolonged labor, or large-for-gestational-age fetus are more prone to uterine atony. Assessing for infection is inappropriate because puerperal infection is not associated with uterine atony. Determining if the uterus has ruptured is inappropriate because uterine atony is not a sign of uterine rupture. Increasing the intravenous fluid rate may be ordered if the client develops symptoms of shock. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
