Examkin

Question

Difficulty: HardAnte/Intra/Postpartum and Newborn Care

A 28-year-old client is 6 hours postpartum following an uncomplicated vaginal delivery. The practical nurse is preparing to evaluate the client's uterine involution and lochia flow. In what order should the nurse perform the following actions? (Arrange the steps from first to last.)

  1. 1Instruct the client to empty their bladder.
  2. 2Assist the client into a supine position with the knees slightly flexed.
  3. 3Apply clean gloves and lower the perineal pad.
  4. 4Place one hand just above the client's symphysis pubis.
  5. 5Cup the other hand around the top of the uterine fundus.

Answer

1. Instruct the client to empty their bladder. 2. Assist the client into a supine position with the knees slightly flexed. 3. Apply clean gloves and lower the perineal pad. 4. Place one hand just above the client's symphysis pubis. 5. Cup the other hand around the top of the uterine fundus.
The correct sequence prioritizes assessment accuracy and client safety. The bladder must be empty first to prevent upward uterine displacement. Next, proper positioning relaxes the abdomen. The nurse then prepares for the physical assessment by donning gloves and exposing the perineum to observe lochia. Finally, the two-handed palpation technique is performed: the lower hand must anchor the uterus at the symphysis pubis before the upper hand assesses the top of the fundus to prevent uterine inversion.

Step-by-Step Solution

1
Ensure the bladder is empty.
The uterus is able to return to its true midline anatomical position.
A distended bladder pushes the uterus up and to the side, causing false assessment findings and increasing the risk of postpartum hemorrhage.
2
Position the client appropriately.
The client's abdominal muscles are fully relaxed.
A supine position with flexed knees reduces abdominal tension, facilitating accurate and comfortable palpation.
3
Don gloves and expose the perineum.
The nurse is protected from biohazardous fluids and can directly visualize lochia flow.
Palpating the fundus often expels pooled blood and clots; the nurse must be able to observe this discharge simultaneously to assess hemorrhage risk.
4
Support the lower uterine segment.
The uterus is firmly anchored in place in the pelvic cavity.
Applying downward pressure on the fundus without first supporting the lower segment can cause the uterus to invert, which is a life-threatening obstetric emergency.
5
Palpate the uterine fundus.
Uterine firmness, height relative to the umbilicus, and location are successfully determined.
This final mechanical action evaluates the progress of normal uterine involution and helps identify the presence of uterine atony.

Key Concept

Postpartum Uterine Assessment Sequence
Rate this question

Topics

Ante/Intra/Postpartum and Newborn Care

More questions from this topic