MEDizzy - A nurse is evaluating the effectiveness of fundal massage on

Feed Library Learning Discuss Leaderboard Journal

Nursing Care for Uncomplicated Pregnancy Labor & Post-partum

A nurse is evaluating the effectiveness of fundal massage on a postpartum client 3 hours after giving birth. An IV infusion of 10 units of oxytocin (Pitocin) is infusing at 100 mL/hr. Her blood pressure is 135/90, the uterus is boggy at 3 cm above the umbilicus and displaced to the right, and her perineal pad is saturated with lochia rubra. What should the nurse do next?

ExplanationB. A displaced and boggy uterus usually is caused by a full bladder; if the bladder is distended, the nurse should have the client void and then reassess the fundus, and if still boggy, massage until firm. A. The oxytocin (Pitocin) infusion may need to be increased if voiding and fundal massage are ineffective; however, the health care provider must be notified to change the prescription. C. This is necessary if the fundus remains boggy after the client has voided. D. This is unnecessary at this time; correcting the boggy fundus is the priority.