2024 HESI Maternity (Labor and Delivery)
Samuel Merit Oaklands New Latest Actual
Exam New Latest Version
Question 1:
The nurse is caring for a client who delivered 6 hours ago. Assessment findings
reveal a boggy uterus that is displaced above and to the right of the umbilicus.
Which action should the nurse take?
A. Encourage voiding
B. Notify healthcare provider
C. Inspect the perineal pad
D. Monitor vital signs
Show correct answer and explanation
Explanation
Encourage voiding:
While promoting voiding is essential to ensure the bladder isn't distended and
causing the uterus to be displaced, this action alone might not resolve the issue
of uterine atony.
Notify healthcare provider:
This is a critical step. Alerting the healthcare provider promptly is necessary
because displaced and boggy uteruses often signal uterine atony, which may
require immediate medical intervention.
Inspect the perineal pad:
Checking the perineal pad can give clues about the amount of lochia
(postpartum vaginal discharge). However, in this scenario, the priority lies in
addressing the potential uterine atony.
Monitor vital signs:
While it's important to monitor vital signs, especially in postpartum clients, the
priority here is recognizing and managing the potential uterine atony.
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