NCLEX Question for Post Partum Assessment

Mrs. P. delivered her baby 12 hours ago. During the postpartum assessment, the uterus is found to be boggy with heavy lochia flow. The initial action of the nurse is to

    a. notify the physician or nurse midwife.
    b. administer prn oxytocin.
    c. encourage the woman to increase ambulation.
    d. massage the uterus until firm.

Correct Answer: D. A soft, boggy, uterus should be massaged until firm; clots may be expressed during massage and this often tends to contract the uterus more effectively.

If the uterus continues not to contract well or the bleeding is excessive, the physician or nurse midwife should be contacted; however, this is not the initial action of the nurse.

If the uterus continues to contract well or the bleeding is excessive, the physician or nurse midwife may order that oxytocin be administered; however, this is not the initial action of the nurse.

Ambulation is advised in the immediate postpartum period; however, this intervention is not related to the emergency situation described.

Posted in: MCN NCLEX