QUESTION: "When assessing an 18-year-old primipara who delivered a viable neonate under epidural anesthesia 24 hours ago, the nurse determines that the fundus is firm but to the right of midline. Based on this finding, the nurse further assesses for which of the following?"
CHOICES
( X ) a.) Uterine inversion.
( X ) b.) Paralytic ileus.
( O ) c.) Urinary retention.
( X ) d.) Perineal hematoma.
RATIONALE: A full bladder is likely to push the uterus to the right of midline, so the nurse should further assess for symptoms of urinary retention. A full bladder can prevent the uterus from contracting properly (uterine atony), possibly leading to hemorrhage. When the bladder is empty, it normally is nonpalpable and lies about in the midline. Uterine inversion occurs when the pressure from palpation pushes the uterus outside the vagina. Abdominal distention, constipation, and pain are commonly associated with a paralytic ileus, which may occur after a cesarean delivery. Perineal hematoma may result from an episiotomy. It has no relation to the fundus being to the right of midline. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
