Massage her fundus. massage the fundus, if boggy, until firm (do not over massage, this fatigues the muscle). RNSG 2203 OB_Questions_for_HESI. A nurse is assessing a client's fundal height. primary nursing intervention for full bladder pushing in uterus uterus deviated from. (5) Nursing interventions. check the quantity of the lochia on the peri pad. Lying prone with a pillow on the abdomen b. A soft or boggy fundus indicates that the uterus isn't contracting properly. Surgical (curettage)—to remove placental fragments. NURS 2130 Pediatrics Final 2020 1. Myometrial contractions are vital to safeguard against excessive (and, potentially fatal) blood loss. A 3-day postpartum client, who is not immune to rubella, is to receive the vaccine at discharge. See full list on myamericannurse. Oxytocics—to stimulate/enhance uterine contractions. F: The physician can be called after massaging the fundus, especially if the fundus does not become or remain firm with massage. Call the physician. Fundus Skills and Assessment Trainer. the first intervention is to massage the fundus until it is firm and to express clots that may have accumulated in the uterus. Discharge: Often associated with foulsmelling lochia and leukorrhea. If uterus boggy--> massage vigorously, let mom nurse NB if possible Boggy fundus, unresponsive to massage Nursing Interventions: Hemorrhagic Shock: Definition. Explain the factors that lead to the separation of mother and infant brought about by the postpartum hemorrhage. To provide information about how a client perceive these role changes that will help in identifying areas of learning need. Massage her fundus. Which of the following nursing interventions would be most The woman's fundus is boggy, midline, and 1 cm below the umbilicus. Fourth stage of labor/Assessment/Fundus 1) After childbirth why is it critical that the uterine fundus stay well contracted? 2) Palpate fundus frequently for the next,,,,? 3) Fundus located? 4) Palpate fundus but do not massage it unless 5) What does boggy uterus indicate?. Slightly boggy and below the umbilicus The uterus here is not firm and not well contracted. Which of the following nursing interventions would be most appropriate initially? Massage the fundus until it is firm. Introduce, Verify pt & allergies, wash hands. Laerdal Upgrade Fundus NSG Anne - Black (325-00450B) The Fundus Skills and Assessment Module features the normal anatomy of the status-post or post-partum female abdomen designed for training fundus assessment and massage skills. Start at the fundus and move. Nursing interventions Promote prevention by encouraging fluids, leg exercises every 1-2 hours, early ambulation. List three nursing interventions to ease the discomfort of afterpains. Following pregnancy, the woman is at risk for infection, hemorrhage, and the development of a deep vein thrombosis (DVT). Which nursing intervention is most helpful in relieving postpartum uterine contractions or afterpains? a. Helps to determine the status of the uterus and may indicate additional interventions. Which nursing intervention would be most appropriate for a postpartum client with a diagnosis of endometritis to facilitate participation in newborn care? A nurse is assessing the fundus in a postpartum woman and notes that the uterus is soft and spongy and is not firmly contracted. During a postpartum assessment, the nurse notes that the uterus is midline and boggy. FOR IMPENDING HEMORRHAGIC SHOCK massage fundus if boggy, elevate legs from hips, IV line, oxygen at 8-10 l/min, stay with patient GDM NURSING INTERVENTIONS. Which of the following nursing interventions would be most Proprofsdiscuss. Excess pressure on a boggy uterus can cause an inverted fundus and result in massive hemorrhage and shock** - Assess for a distended bladder. The fundus should be firm, not soft. 800 mcg of Misoprostol Rectal – unable to determined effectiveness dur to onset. Oxytocics—to stimulate/enhance uterine contractions. Describe the 3 stages of lochia and the time period for each. (b) Massage the fundus, if boggy, until firm (do not over massage, this fatigues the muscle). >>NCLEX Review Questions — Test Yourself! (Parts 2-4)<< #11. bimanual uterine compression massage is performed by placing one hand in the vagina and pushing against the body of the uterus while the other hand. There are four stages to nursing interventions. >2 24 hours norm and normal Variations Refer to POS Increased flow on standing, activity or breastfeeding Should not exceed moderate range Client education/ Anticipatory Guidance. fundus, Complain of pain and “I think I am peeing” Pool of blood. , vital signs, assessment findings, blood loss, nursing interventions, and patient response). Massage the boggy fundus to stimulate it to become firm again, or give patient Pitocin, or have the patient breastfeed. eval/treat boggy uterus & full bladder; pharmacy & non-pharmacy relief of pain/discomfort 81. bimanual uterine compression massage is performed by placing one hand in the vagina and pushing against the body of the uterus while the other hand. Which of the following nursing interventions would be most appropriate initially?. ABDOMEN / FUNDUS Assess --Fundus for normal involution UptoDate1 --Refer to UptoDate for detailed postpartum assessment data to The Postpartum Nursing Care Pathway recommends that the 5 following criteria define postpartum physiologic stability for vaginal delivery at term. A nurse is preparing to assess the uterine fundus of a client in the immediate postpartum period. Since uterine atony is the cause of a majority of postpartum hemorrhage, interventions are first directed at addressing the causes of loss of tone. As a nursing student, you must be familiar with each stage of labor and the nursing interventions based on the specific stage of labor. Encourage all moms to wear a support bra whether nursing or non-nursing. NURS 2130 Pediatrics Final 2020 1. fundus, Complain of pain and “I think I am peeing” Pool of blood. Nursing Care Plan: The Ultimate Guide and Database – the ultimate database of nursing care plans for different diseases and conditions! Get the complete list! Nursing Diagnosis: The Complete Guide and List – archive of different nursing diagnoses with their definition, related factors, goals and nursing interventions with rationale. Nursing Assessment & Interventions for Post-Traumatic Stress Disorder (PTSD). Boggy uterus: massage and assess trickling from vagina and urinary retention Fundus palpation, normal finding postpartum day 1: firm on palpation, 1 – 2 fingerbreadths below the umbilicus Pain assessment: accurate indicator - patient’s description of pain Phlebitis in one leg post-Cesarean, apply SCD only to uninvolved leg. Fundus descends about 1 fingerbreadth or 1 cm daily ? Descends into pelvis on 10 th day, can no longer be palpated ? Returns to pre-preg size If episiotomy - scared will hurt or tear sutures with BM ? Nursing interventions may help prevent, relieve ? If C/S, clear liq till bowel sounds, then solid food. Lying prone with a pillow on the abdomen b. 6 Nursing Interventions for Glaucoma. Monitor/palpate fundus for location/tone. When the nurse locates the fundus, she notes that the uterus feels soft and boggy. Make sure the uterus is not inverted (occurs in 0. Immediately after delivery, fundus is 2 cm below umbilicus, 12 hours later it is 1 cm above umbilicus. )Boggy, midway between the umbilicus and symphysis pubis C. Learn Postpartum Hemorrhage - Postpartum Period - Obstetrics - Picmonic for Nursing RN faster and easier with Picmonic's unforgettable videos, stories, and quizzes! Picmonic is research proven to increase your memory retention and test scores. Encourage all moms to wear a support bra whether nursing or non-nursing. (5) Nursing interventions. When the nurse locates the fundus. Rationale: Most of the nursing interventions during the postpartum period are directed toward helping the mother successfully adapt to the parenting role. Contraction of the uterine muscles during labor compresses the blood vessels and slows flow, which helps prevent hemorrhage and facilitates coagulation. Chan Age/ sex: 48/F Medical diagnosis: Fluid overload, decreased TK output and decreased Hb Assessment date: 25-11-2012 Diagnostic statement (PES): Excess fluid volume related to compromised regulatory mechanism secondary to end-stage renal failure as evidence by peripheral edema and patient’s weight. Using a breast pump c. Massage the fundus until firm and reevaluate within 30 minutes c. Explain assessment Perform Vital signs Perform Post-partum assessment Nurse lifts blanket Place supine, assess fundus (midline & boggy) Massage fundus, boggy, bleeding continues. Place her on a bedpan to empty her bladder. Nursing interventions: - Massage uterus if not firm - Express clots - **Do not push on uterus if it is not firm. Nursing Interventions Rationale; Discuss client’s view of infant care responsibilities and parenting role. Rationale: a. intervenously fluids administered to increase fluid and blood volume. Medical management: Have woman void or catheterize; massage fundus. When the nurse locates the fundus, she notes that the uterus feels soft and boggy. Common nursing interventions include. Explain assessment Perform Vital signs Perform Post-partum assessment Nurse lifts blanket Place supine, assess fundus (midline & boggy) Massage fundus, boggy, bleeding continues. What is massage the fundus? 100. The woman should pump and dump her breast milk for 1 week. Nursing Care Plan Kimberly LaPointeN620C Maternity University of New Hampshire Department of Nursing Spring 2008 Patricia Puccilli RN, MS Date gathered: March 7, 2008 Overview of the clinical situation T. Lochia normal. 800 mcg of Misoprostol Rectal – unable to determined effectiveness dur to onset. escort her to the bathroom 4. When the nurse locates the fundus, she notes that the uterus feels soft and boggy. Nursing intervention to restore good uterine tone; Priority nursing intervention for postpartum hemorrhage; Priority nursing intervention for a client with a boggy uterus. Antibiotic therapy—to treat intrauterine infection. Which nursing intervention is most helpful in relieving postpartum uterine contractions or afterpains? a. Fundus is slightly boggy but firms with massage at 2 finger breadths above umbilicus, and is deviated to the right She also has moderate lochia and she isn’t moving around too much Lightly massage the fundus in a circular motion if boggy. She is a G2 P2002, delivered a 4 kg baby boy at 41 1/7 weeks gestation. Interchangeable firm contracted and "boggy" uteri. Technique of bimanual massage for uterine atony. Cupping the dominant hand around the fundus and placing the other hand just above the pubic symphysis to support the lower uterine segment, the attendant gently massages the uterine fundus. Learn more about nursing interventions, the NIC system and more. The Fundus Skills and Assessment Trainer features the normal anatomy of the status-post or post-partum female abdomen designed for training fundus assessment and massage skills. Uterine involution normal and uterus is not tender. Massage the fundus until firm and reevaluate within 30 minutes c. To provide information about how a client perceive these role changes that will help in identifying areas of learning need. the first intervention is to massage the fundus until it is firm and to express clots that may have accumulated in the uterus. prevent bladder distention. Goal: Pain is reduced and the client is on the comfort level. The process that results in the rapid healing of the birth canal and the return of the uterus and all systems to or almost to the pre-pregnant state. Massage the fundus until it is firm 2. Following pregnancy, the woman is at risk for infection, hemorrhage, and the development of a deep vein thrombosis (DVT). For nurses considering advancement, nursing interventions are a crucial concept to master. Which of the following must the nurse include in her discharge teaching regarding the vaccine? a. A woman is 1 day postpartum. Teach the patient how to apply graduate compression stockings and encourage the use of sequential compression stockings when in bed. The perineum is between the urethra, the tube that carries urine from the bladder, and the anus. Immediately palpate uterine fundus and confirm if contracted. fundus one centimeter above umbilicus and boggy with pulse of 110. After Birth and IWK Health Centre Policy 40060 - Nursing Care of the Newborn. Outcomes research done abroad also is mentioned. Using a breast pump c. Obviously that's just an immediate life-saving intervention when a patient is having flash pulmonary edema and we're trying to maintain them till they can get to a CPAP, a medic truck, or an ER. she notes that the uterus feels soft and boggy. Acute Pain related to an increase in IOP. Lochia normal. Massage the boggy fundus to stimulate it to become firm again, or give patient Pitocin, or have the patient breastfeed. Lying prone with a pillow on the abdomen b. Fundus 1 fingerbreadth below the umbilicus On postpartum day 1, the fundus should normally be 1 fingerbreadth below the umbilicus. The nurse's initial action would be to call the physician. To notify the patients midwife or physician b. These patients often require general anesthesia as reduction is extremely. The woman's fundus is boggy, midline, and 1 cm below the umbilicus. The woman's fundus is boggy, midline, and 1 cm below the umbilicus. escort her to the bathroom 4. Which of the following nursing interventions would be most The woman's fundus is boggy, midline, and 1 cm below the umbilicus. primary nursing intervention for full bladder pushing in uterus uterus deviated from. Nursing Diagnosis and Interventions for Glaucoma. The presence of a boggy uterus with either heavy vaginal bleeding or increasing uterine size can suspect diagnosis of uterine atony. Contraction of the uterine muscles during labor compresses the blood vessels and slows flow, which helps prevent hemorrhage and facilitates coagulation. Nursing Interventions Rationale; Discuss client’s view of infant care responsibilities and parenting role. The uterine tone and size will be assessed by using a hand resting on the fundus and palpating the anterior wall of the uterus one hour after the operation. A nurse is preparing to assess the uterine fundus of a client in the immediate postpartum period. Signs of uterine atony include a boggy uterus, a fundus that is higher than expected upon palpation, and excessive lochia. Fourth stage of labor/Assessment/Fundus 1) After childbirth why is it critical that the uterine fundus stay well contracted? 2) Palpate fundus frequently for the next,,,,? 3) Fundus located? 4) Palpate fundus but do not massage it unless 5) What does boggy uterus indicate?. I'm sure there are numerous obtuse nursing interventions for a nursing process worksheet. Which nursing action is appropriate for the client 1 hour after birth with findings of a fundus that is boggy, midline, and 1 cm below the umbilicus and a lochial flow that is profuse, with two plum-sized clots?. In women, the perineum includes the vaginal opening. Administer: Straight catheterization if unable to void Medications as ordered Stool softener if ordered Consistency is recorded as "fundus firm with massage" or "fundus boggy. Some times the perineum needs to be surgically cut during labor (episiotomy) or it tears naturally during delivery. The process that results in the rapid healing of the birth canal and the return of the uterus and all systems to or almost to the pre-pregnant state. Using a breast pump c. The fundus should be firm, not soft. Chapter 13: Nursing Care During Labor And Birth Answer Sheet For Test Chapter 14 Test Bank Exam Chapter 25 Test Bank Other related documents Museum Paper - Grade: A Psych NURS EXAM 3BluePrint Chapter 18 Exam Chapter 20 Exam Chapter 30 Test Bank STUDY GUIDE FOR FINAL EXAM. Recognize patient is having a PPH. Monitor the fundus of the uterus for firmness: it should be firm and midline, and at or slightly below the umbilicus…. Do not apply excessive pressure on the fundus of the uterus as this may increase the risk of inversion. Our online obstetrical nursing trivia quizzes can be adapted to suit your requirements for taking some of the top obstetrical nursing quizzes. >2 24 hours norm and normal Variations Refer to POS Increased flow on standing, activity or breastfeeding Should not exceed moderate range Client education/ Anticipatory Guidance. Page 410 of book. monitor patient's vital signs every 15 minutes until stable. The nursing intervention used when assessment of uterus is found to be boggy. Fundus is boggy when it is not firm, may indicate hemorrhage. Signs of uterine atony include a boggy uterus, a fundus that is higher than expected upon palpation, and excessive lochia. A soft or boggy fundus indicates that the uterus isn't contracting properly. Nursing interventions and assessments are two separate steps in a larger nursing process. Which nursing intervention is most helpful in relieving postpartum uterine contractions or afterpains? a. Our mission is to Empower, Unite, and Advance every nurse, student, and educator. TIME LOC Breasts Nipples Fundus Bladder Lochia Perineum Hemorrhoids Edema Homans Sign Activity Maternal/ Infant Bond Family Involvement Initial As Ordered Pericare Sitz Bath Other Analgesia (document. The nurse must report a PPH immediately and prepare for the insertion of a large-bore intravenous catheter, if one is not already present, and the administration of intravenous fluids and oxygen. Massage her fundus. Administer: Straight catheterization if unable to void Medications as ordered Stool softener if ordered Consistency is recorded as "fundus firm with massage" or "fundus boggy. Immediately palpate uterine fundus and confirm if contracted. Give Syntocinon as per orders d. prevent bladder distention. • Bowels are sluggish d/t progesterone and decreased abdominal musculature leading to A boggy uterus, a displaced uterus, or a palpable bladder are signs of bladder distension and require nursing intervention. Massaging the abdomen d. Which of the following nursing interventions would be most appropriate initially?. Assist the patient to the bathroom and ask her to void. Interventions proceed from least invasive to most inva-sive. Breastfeeding enhances involution because sucking stimulates the release of oxytocin from the posterior pituitary gland. When the nurse locates the fundus. What is the first thing you do? 1. Apr 26, 2018 - Explore Jamie Ferguson's board "Awesome" on Pinterest. Encourage all moms to wear a support bra whether nursing or non-nursing. Understanding that a boggy fundus and bladder distension can lead to uterine atony and ultimately PPH is very important because not only is it a possibility for all postpartum women but PPH is a potentially life threatening condition that requires immediate identification and intervention. 6 Nursing Interventions for Glaucoma. Encourage the mother to empty her bladder before she breastfeeds. (c) Monitor patient’s vital signs every 15 minutes until stable. Auscultate bowel sounds and inquire daily about BMs. Chan Age/ sex: 48/F Medical diagnosis: Fluid overload, decreased TK output and decreased Hb Assessment date: 25-11-2012 Diagnostic statement (PES): Excess fluid volume related to compromised regulatory mechanism secondary to end-stage renal failure as evidence by peripheral edema and patient’s weight. There are four stages to nursing interventions. Goal: Pain is reduced and the client is on the comfort level. Monitor the fundus of the uterus for firmness: it should be firm and midline, and at or slightly below the umbilicus…. Nursing Assessment & Interventions for Post-Traumatic Stress Disorder (PTSD). The woman's fundus is boggy, midline, and 1 cm below the umbilicus. The nurse examines a woman 1 hour after birth. The nurse's initial action would be to call the physician. massage the fundus 3. The nurse measures the fundus of the postpartum patient. Massage the fundus to help it become firm and to express clots that may have accumulated within (do not push on. On last assessment fundus was still soft & boggy. Signs of uterine atony include a boggy uterus, a fundus that is higher than expected upon palpation, and excessive lochia. Monitor/palpate fundus for location/tone. Assess and record the type, amount, and site of the bleeding; Count and weigh perineal pads and if Assess the location of the uterus and degree of the contractility of the uterus/ Massage boggy uterus using one hand and place the second hand above the symphysis pubis. (b) Massage the fundus, if boggy, until firm (do not over massage, this fatigues the muscle). What instruction needs to be given before palpating her bladder? 5. Call the physician. Medical management: Have woman void or catheterize; massage fundus. Her lochia is rubra and moderate and her fundus is 2 cm above the umbilicus, boggy, and deviated to the right. Excess pressure on a boggy uterus can cause an inverted fundus and result in massive hemorrhage and shock** - Assess for a distended bladder. Nursing interventions during postpartum hemorrhage? 1. Boggy uterus on assessment or puddle of blood or constant ooze or trickle Saturating pads within 15 minutes or puddle of blood in bed Remember that chucks pad under the patient Signs of shock – decreased LOC, restless, pale, diaphoretic, hypotensive, tachycardic, weak. A soft or boggy fundus isn't contracting well due to such factors as a full bladder or retained pieces of placenta and places the postpartum woman at risk for hemorrhage. (a) Explain condition and treatment. The woman should not become pregnant for at least 4 weeks. Massage of the uterine fundus can aid in uterine muscle contraction. Lying prone with a pillow on the abdomen b. Discharge: Often associated with foulsmelling lochia and leukorrhea. Our members represent more than 60 professional nursing specialties. What does this indicate? 4. fundus, Complain of pain and “I think I am peeing” Pool of blood. Discuss the 9 areas of postpartum physical assessment (Bubble He). Product benefits: Educationally effective for in-hospital practice of postpartum physical assessment including identification and treatment of normal and abnormal. The nurse's initial action would be to: a. When the nurse locates the fundus, she notes that the uterus feels soft and boggy. uterus large and boggy. eval/treat boggy uterus & full bladder; pharmacy & non-pharmacy relief of pain/discomfort 81. Assess and record the type, amount, and site of the bleeding; Count and weigh perineal pads and if Assess the location of the uterus and degree of the contractility of the uterus/ Massage boggy uterus using one hand and place the second hand above the symphysis pubis. (c) Monitor patient’s vital signs every 15 minutes until stable. Fundus is slightly boggy but firms with massage at 2 finger breadths above umbilicus, and is deviated to the right She also has moderate lochia and she isn’t moving around too much Lightly massage the fundus in a circular motion if boggy. Signs of uterine atony include a boggy uterus, a fundus that is higher than expected upon palpation, and excessive lochia. bladder distention displaces the uterus and prevents effective uterine contractions. Medical management: Have woman void or catheterize; massage fundus. Constipation is common from anesthesia and analgesics as well as fear of perineal pain. An empty bladder will allow the uterus to contract more efficiently and decreases the discomfort. Hyper vs Hypothyroidism; Hyper vs HypoPARAthyroidism; Addison’s vs Cushing’s. Immediately palpate uterine fundus and confirm if contracted. Encourage skin to skin and breastfeeding. Boggy means bleeding and needs interventions. 800 mcg of Misoprostol Rectal – unable to determined effectiveness dur to onset. The term describes any action nurses may take to improve the health and comfort of their. When the nurse locates the fundus. EXAM 3 1 ATI FINAL MATERNAL HEALTH EXAM 3 Postpartum Hemorrhage PPH From delivery up to 6wks postpartum SVD Spontaneous vaginal delivery: greater than 500ml considered PPH o Estimated blood loss o Quantitative blood loss weighing everything CS C-Section: greater than 1000ml Two main reasons for PPH Full bladder Retained placenta What you will assess when you walk into a patient’s room for. A soft or boggy fundus indicates that the uterus isn't contracting properly. After these steps or in parallel, evaluate the uterus. This video provides an overview of Chronic Obstructive Pulmonary Disease (COPD) interventions for care. This is a joyous time, but it’s also a period of. F: The physician can be called after massaging the fundus, especially if the fundus does not become or remain firm with massage. UTERUS: It is firm or is it boggy? The fundus should be firm; if not, gently massage to obtain firmness and note if excess bleeding or clots are expelled during the massage. Rationale: Most of the nursing interventions during the postpartum period are directed toward helping the mother successfully adapt to the parenting role. Massage the boggy fundus to stimulate it to become firm again, or give patient Pitocin, or have the patient breastfeed. Do not apply excessive pressure on the fundus of the uterus as this may increase the risk of inversion. Massage the fundus until firm and reevaluate within 30 minutes c. See full list on jognn. Interventions are the backbone of nursing. docx OB Questions for HESI 1. 19- A nurse is preparing to assess the uterine fundus of a client in the immediate postpartum period. OB HESI 2 TEST BANKLATEST : ASSURED 100% SATISFACTIONS } BEST DOCUMENT FOR YOUR EXAMOB HESI 2 TEST BANK Which nursing intervention is most helpful in relieving postpartum uterine contractions or afterpains? a. Recovery and Care After Delivery. A fundus that is above the. Nursing Assessment and Management of Postpartum Hemorrhage Prompt assessment and management can minimize blood loss. _____ (Initials) Refer To Initial Postpartum Clinical Pathway DATE/SHIFT Care Plan review by _____, R. K-5-6 Demonstrate ability to recognize physiological changes such as:. >>NCLEX Review Questions — Test Yourself! (Parts 2-4)<< #11. Obviously that's just an immediate life-saving intervention when a patient is having flash pulmonary edema and we're trying to maintain them till they can get to a CPAP, a medic truck, or an ER. After these steps or in parallel, evaluate the uterus. A 3-day postpartum client who is not immune to rubella is to receive the vaccine at discharge. What is the concern with a boggy fundus, and what should be done. The first is the assessment, in which the nurse what are nursing responsibilities or nursing interventions for wound dressing? please help me. The perineum is between the urethra, the tube that carries urine from the bladder, and the anus. Fundus is boggy when it is not firm, may indicate hemorrhage. You will be providing care a 28‐year‐old female who is 2 hours postpartum from a vaginal delivery. A 3-day postpartum client, who is not immune to rubella, is to receive the vaccine at discharge. Massage the fundus to help it become firm and to express clots that may have accumulated within (do not push on. When the nurse locates the fundus, she notes that the uterus feels soft and boggy. The Fundus Skills and Assessment Trainer features the normal anatomy of the status-post or post-partum female abdomen designed for training fundus assessment and massage skills. The fundus should be firm, not soft. monitor vitals 2. The uterine tone and size will be assessed by using a hand resting on the fundus and palpating the anterior wall of the uterus one hour after the operation. Her lochial flow is profuse, with two plum-sized clots. The woman's fundus is boggy, midline, and 1 cm below the umbilicus. Giving oxytocic medications a. A soft or boggy fundus isn't contracting well due to such factors as a full bladder or retained pieces of placenta and places the postpartum woman at risk for hemorrhage. The nurse measures the fundus of the postpartum patient. Helps to determine the status of the uterus and may indicate additional interventions. Fundus Skills and Assessment Trainer. Healing after childbirth often requires special care for the perineum. Which of the following nursing interventions would be most appropriate initially?. When the fundus is firm, gentle downward pressure expresses any clots that have accumulated in the uterine cavity. Her lochial flow is profuse, with two plum-sized clots. Monitor the fundus of the uterus for firmness: it should be firm and midline, and at or slightly below the umbilicus…. in Fundus section Intervention Infection Nursing assessment Refer to Intervention Infection in Fundus section. The woman should not become pregnant for at least 4 weeks. _____ (Initials) Refer To Initial Postpartum Clinical Pathway DATE/SHIFT Care Plan review by _____, R. Excess pressure on a boggy uterus can cause an inverted fundus and result in massive hemorrhage and shock** - Assess for a distended bladder. When the nurse locates the fundus. If postvoid uterus is still boggy, massage top of fundus with fingers held together and reassess every 15 minutes. Which nursing action is appropriate for the client 1 hour after birth with findings of a fundus that is boggy, midline, and 1 cm below the umbilicus and a lochial flow that is profuse, with two plum-sized clots?. Hyper vs Hypothyroidism; Hyper vs HypoPARAthyroidism; Addison’s vs Cushing’s. The fundus should be firm, not soft. UTERUS: It is firm or is it boggy? The fundus should be firm; if not, gently massage to obtain firmness and note if excess bleeding or clots are expelled during the massage. In women, the perineum includes the vaginal opening. During the quiz, you'll be expected to know the ins and outs of how to educate. When the nurse locates the fundus, she notes that the uterus feels soft and boggy. A soft or boggy fundus isn't contracting well due to such factors as a full bladder or retained pieces of placenta and places the postpartum woman at risk for hemorrhage. A nurse is preparing to assess the uterine fundus of a client in the immediate postpartum period. What're you going to do for hemorrhoids?. Nursing intervention to restore good uterine tone; Priority nursing intervention for postpartum hemorrhage; Priority nursing intervention for a client with a boggy uterus. How do you document fundal height? 6. Options B and D: Elevating the clients legs and encouraging the client to void will not assist in managing. Observation and prevention of bladder distention is an important postpartum nursing responsibility (see Figure 17-1). Cupping the dominant hand around the fundus and placing the other hand just above the pubic symphysis to support the lower uterine segment, the attendant gently massages the uterine fundus. Nursing Interventions for Labor Pain: Labor is a life-changing and precious moment for a pregnant woman. Which of the following nursing interventions would be most appropriate initially?. primary nursing intervention for full bladder pushing in uterus uterus deviated from. Assess and record the type, amount, and site of the bleeding; Count and weigh perineal pads and if Assess the location of the uterus and degree of the contractility of the uterus/ Massage boggy uterus using one hand and place the second hand above the symphysis pubis. The client has just started her third trimester of pregnancy. Nursing Diagnosis and Interventions for Glaucoma. 05% of deliveries). Massage the fundus. Lying prone with a pillow on the abdomen. The nurse measures the fundus of the postpartum patient. Her lochia is rubra and moderate and her fundus is 2 cm above the umbilicus, boggy, and deviated to the right. Our members represent more than 60 professional nursing specialties. Fundus is boggy when it is not firm, may indicate hemorrhage. On last assessment fundus was still soft & boggy. After these steps or in parallel, evaluate the uterus. What is massage the fundus? 100. Options B and D: Elevating the clients legs and encouraging the client to void will not assist in managing. Administer prescribed anticoagulants and teach patient about administered medications. Nursing Care Plan Table 1 Nursing Care Plan Assessment Nursing Diagnosis Outcomes Nursing Interventions Rational Evaluation Postpartum VS At risk for bleeding for a decrease in blood volume r/t postpartum period (Sparks & Taylor, 2014). escort her to the bathroom 4. Boggy uterus or uterine atony is defined as failure of the myometrium to contract and retract around the open blood vessels of the uteroplacental implantation site following childbirth 3). Technique of bimanual massage for uterine atony. >>NCLEX Review Questions — Test Yourself! (Parts 2-4)<< #11. Which of the following nursing interventions would be most appropriate initially?. The uterus : Often remains boggy and soft with tenderness over the fundus, and pain on moving the cervix on bimanual examination. Product benefits: Educationally effective for in-hospital practice of postpartum physical assessment including identification and treatment of normal and abnormal. Indicative of uterine atony (loss of uterine musculature), if not corrected, results in PP Engorgement is when the breast is not being emptied enough d/t baby not nursing rigorously enough, separation from baby, not nursing enough. UTERUS: It is firm or is it boggy? The fundus should be firm; if not, gently massage to obtain firmness and note if excess bleeding or clots are expelled during the massage. Myometrial contractions are vital to safeguard against excessive (and, potentially fatal) blood loss. The woman should not become pregnant for at least 4 weeks. Helps to determine the status of the uterus and may indicate additional interventions. 19- A nurse is preparing to assess the uterine fundus of a client in the immediate postpartum period. thank you so much. Which of the following must the nurse include in her discharge teaching regarding the vaccine? a. The immediate nursing action is:a. Slightly boggy and below the umbilicus The uterus here is not firm and not well contracted. in Fundus section Intervention Infection Nursing assessment Refer to Intervention Infection in Fundus section. It is considered to be the disorder with mood which is commonly in women during a specific phase of childbirth. The nursing intervention used when assessment of uterus is found to be boggy. Options B and D: Elevating the clients legs and encouraging the client to void will not assist in managing uterine atony. There are four stages to nursing interventions. Interventions proceed from least invasive to most inva-sive. _____ (Initials) Refer To Initial Postpartum Clinical Pathway DATE/SHIFT Care Plan review by _____, R. The mother must wear a surgical mask when. nursing intervention. After 12 hrs you could feel it back in the umbilicus again. assess bladder for distention 2. NURS 2130 Pediatrics Final 2020 1. Safety nursing interventions include actions that maintain a patient's safety and prevent injuries. 19- A nurse is preparing to assess the uterine fundus of a client in the immediate postpartum period. Administer: Straight catheterization if unable to void Medications as ordered Stool softener if ordered Consistency is recorded as "fundus firm with massage" or "fundus boggy. Uterine involution normal and uterus is not tender. Indicative of uterine atony (loss of uterine musculature), if not corrected, results in PP Engorgement is when the breast is not being emptied enough d/t baby not nursing rigorously enough, separation from baby, not nursing enough. The woman should not become pregnant for at least 4 weeks. What does this indicate? 4. Immediately palpate uterine fundus and confirm if contracted. For nurses considering advancement, nursing interventions are a crucial concept to master. massage the fundus 3. After these steps or in parallel, evaluate the uterus. Nursing interventions involve a nurse furthering a patient's course of treatment. TIME LOC Breasts Nipples Fundus Bladder Lochia Perineum Hemorrhoids Edema Homans Sign Activity Maternal/ Infant Bond Family Involvement Initial As Ordered Pericare Sitz Bath Other Analgesia (document. Rationale: a. NURS 2130 Pediatrics Final 2020 1. Fundus is boggy when it is not firm, may indicate hemorrhage. Medical and nursing interventions. Uterine involution normal and uterus is not tender. Discuss the 9 areas of postpartum physical assessment (Bubble He). The uterine tone and size will be assessed by using a hand resting on the fundus and palpating the anterior wall of the uterus one hour after the operation. Fundus is to the right. Variance – Fundus - Uterus – boggy, soft, deviated to one side (due to retained products, distended bladder, uterine atony, bleeding) Intervention – Fundus - Massage uterus (if boggy) – advise to empty bladder - May require further interventions – e. Nursing interventions: - Massage uterus if not firm - Express clots - **Do not push on uterus if it is not firm. Nursing Care Plan: The Ultimate Guide and Database – the ultimate database of nursing care plans for different diseases and conditions! Get the complete list! Nursing Diagnosis: The Complete Guide and List – archive of different nursing diagnoses with their definition, related factors, goals and nursing interventions with rationale. A 3-day postpartum client who is not immune to rubella is to receive the vaccine at discharge. Some times the perineum needs to be surgically cut during labor (episiotomy) or it tears naturally during delivery. (c) Monitor patient’s vital signs every 15 minutes until stable. OB HESI 2 TEST BANKLATEST : ASSURED 100% SATISFACTIONS } BEST DOCUMENT FOR YOUR EXAMOB HESI 2 TEST BANK Which nursing intervention is most helpful in relieving postpartum uterine contractions or afterpains? a. There are four stages to nursing interventions. The woman should not become pregnant for at least 4 weeks. A comprehensive database of more than 16 obstetrical nursing quizzes online, test your knowledge with obstetrical nursing quiz questions. Surgical (curettage)—to remove placental fragments. Start learning today for free!. What nursing interventions can the nurse perform? Definition. To notify the patients midwife or physician b. For nurses considering advancement, nursing interventions are a crucial concept to master. The nurse must report a PPH immediately and prepare for the insertion of a large-bore intravenous catheter, if one is not already present, and the administration of intravenous fluids and oxygen. Which of the following nursing interventions would be most appropriate initially? Massage the fundus until it is firm. Encourage the mother to empty her bladder before she breastfeeds. So breast care education will be an intervention, uterine massage if the uterus is boggy or bleeding, stool softeners for constipation, tucks pads for hemorrhoid care, ice packs for the perineal swelling, compression hose to prevent blood clots, and any intervention we can do to promote care and bonding. What is the first thing you do? 1. It is considered to be the disorder with mood which is commonly in women during a specific phase of childbirth. Following pregnancy, the woman is at risk for infection, hemorrhage, and the development of a deep vein thrombosis (DVT). Giving oxytocic medications Lying prone A keeps the fundus contracted and is especially useful with. uterus, fundus rises and becomes boggy (uterine atony) Ovulation and Menstruation/Lactation and ascertain position approximate descent of 1 cm or 1 fingerbreadth per day If boggy (soft) family Include parents in nursing intervention Reaction of Siblings Sibling visits reassure children their. EXAM 3 1 ATI FINAL MATERNAL HEALTH EXAM 3 Postpartum Hemorrhage PPH From delivery up to 6wks postpartum SVD Spontaneous vaginal delivery: greater than 500ml considered PPH o Estimated blood loss o Quantitative blood loss weighing everything CS C-Section: greater than 1000ml Two main reasons for PPH Full bladder Retained placenta What you will assess when you walk into a patient’s room for. Nursing interventions involve a nurse furthering a patient's course of treatment. Elevate the mothers legs. I am Gail L Lupica with over 20 years of experience. Nursing & Patient Care. Product benefits: Educationally effective for in-hospital practice of postpartum physical assessment including identification and treatment of normal and abnormal. NR327 Exam 2 Review Questions #9 Care of the High-Risk Mother Newborn & Family With Special Needs aka Postpartum Maternal Complications 28 2/5/2019 9 NR327 Exam 2 Review Questions #9 Care of the High-Risk Mother Newborn & Family With Special Needs aka Postpartum Mater… 9 NR327 Exam 2 Review Questions #9 Care of the High-Risk Mother Newborn & Family With Special Needs aka. Nursing Care Plan Kimberly LaPointeN620C Maternity University of New Hampshire Department of Nursing Spring 2008 Patricia Puccilli RN, MS Date gathered: March 7, 2008 Overview of the clinical situation T. Fundus 1 fingerbreadth below the umbilicus On postpartum day 1, the fundus should normally be 1 fingerbreadth below the umbilicus. What does this indicate? 4. Massaging the abdomen d. The mother must wear a. Discuss the 9 areas of postpartum physical assessment (Bubble He). List three nursing interventions to ease the discomfort of afterpains. The perineum is between the urethra, the tube that carries urine from the bladder, and the anus. bladder distention displaces the uterus and prevents effective uterine contractions. Observation and prevention of bladder distention is an important postpartum nursing responsibility (see Figure 17-1). UTERUS: It is firm or is it boggy? The fundus should be firm; if not, gently massage to obtain firmness and note if excess bleeding or clots are expelled during the massage. (b) Massage the fundus, if boggy, until firm (do not over massage, this fatigues the muscle). Giving oxytocic medications Lying prone A keeps the fundus contracted and is especially useful with. After Birth and IWK Health Centre Policy 40060 - Nursing Care of the Newborn. Uterine atony is the failure of the uterus to contract adequately following delivery. 05% of deliveries). In these examples, the measurement of outcomes includes behavioral indicators (in italics) as well as physiologic and organizational ones. >>NCLEX Review Questions — Test Yourself! (Parts 2-4)<< #11. Nursing management: Goal: health teaching. Lochia normal. Boggy uterus or uterine atony is defined as failure of the myometrium to contract and retract around the open blood vessels of the uteroplacental implantation site following childbirth 3). Nursing Care Plan: The Ultimate Guide and Database – the ultimate database of nursing care plans for different diseases and conditions! Get the complete list! Nursing Diagnosis: The Complete Guide and List – archive of different nursing diagnoses with their definition, related factors, goals and nursing interventions with rationale. Antibiotic therapy—to treat intrauterine infection. The Fundus Skills and Assessment Trainer features the normal anatomy of the status-post or post-partum female abdomen designed for training fundus assessment and massage skills. Nursing interventions Promote prevention by encouraging fluids, leg exercises every 1-2 hours, early ambulation. Using a breast pump c. K-5-5 Demonstrate ability to provide appropriate nursing interventions. _____ (Initials) Refer To Initial Postpartum Clinical Pathway DATE/SHIFT Care Plan review by _____, R. Which nursing intervention would be most appropriate for a postpartum client with a diagnosis of endometritis to facilitate participation in newborn care? A nurse is assessing the fundus in a postpartum woman and notes that the uterus is soft and spongy and is not firmly contracted. Fundus Skills and Assessment Trainer. Monitor the fundus of the uterus for firmness: it should be firm and midline, and at or slightly below the umbilicus…. Lateral deviation can indicate a full bladder. Explain assessment Perform Vital signs Perform Post-partum assessment Nurse lifts blanket Place supine, assess fundus (midline & boggy) Massage fundus, boggy, bleeding continues. In women, the perineum includes the vaginal opening. Lying prone with a pillow on the abdomen b. Flexible module designed for teaching: - Interventions for excessive postpartum bleeding including fundal massage and prevention of Realistic landmark of the symphysis pubis. How do you document fundal height? 6. Discharge: Often associated with foulsmelling lochia and leukorrhea. These patients often require general anesthesia as reduction is extremely. Assessment: difficulty locating fundus; soft or boggy fundus; location of fundus above expected level; excessive lochia, especially bright red; and expulsion of an excessive number of clots. Laerdal Upgrade Fundus NSG Anne - Black (325-00450B) The Fundus Skills and Assessment Module features the normal anatomy of the status-post or post-partum female abdomen designed for training fundus assessment and massage skills. Nursing Interventions. Interventions proceed from least invasive to most inva-sive. Nursing Assessment & Interventions for Post-Traumatic Stress Disorder (PTSD). Which of the following nursing interventions would be most appropriate initially?. Massage of the uterine fundus can aid in uterine muscle contraction. To notify the patients midwife or physician b. OB HESI 2 TEST BANKLATEST : ASSURED 100% SATISFACTIONS } BEST DOCUMENT FOR YOUR EXAMOB HESI 2 TEST BANK Which nursing intervention is most helpful in relieving postpartum uterine contractions or afterpains? a. Laerdal Upgrade Fundus NSG Anne - Black (325-00450B) The Fundus Skills and Assessment Module features the normal anatomy of the status-post or post-partum female abdomen designed for training fundus assessment and massage skills. After these steps or in parallel, evaluate the uterus. " Record fundal height (e. What nursing interventions can the nurse perform? Definition. Ask wife to hold infant. It is considered to be the disorder with mood which is commonly in women during a specific phase of childbirth. The nurse's initial action. If postvoid uterus is still boggy, massage top of fundus with fingers held together and reassess every 15 minutes. Her lochial flow is profuse, with two plum-sized clots. Boggy uterus on assessment or puddle of blood or constant ooze or trickle Saturating pads within 15 minutes or puddle of blood in bed Remember that chucks pad under the patient Signs of shock – decreased LOC, restless, pale, diaphoretic, hypotensive, tachycardic, weak. Safety nursing interventions include actions that maintain a patient's safety and prevent injuries. if soft/boggy or displaced perform: fundus massage and want to make sure bladder is empty so have the patient void (will be checking fundus every 15 minutes for 1 hour then 30 minutes for 2 hours). boggy fundus client passing large clots or tissue difficulty voiding or distended bladder displaced fundus edema (hands and feet) high blood pressure postpartum hemorrhage seizure activity. Outcomes research done abroad also is mentioned. Make sure the uterus is not inverted (occurs in 0. Describe the 3 stages of lochia and the time period for each. Which of the following nursing interventions would be most The woman's fundus is boggy, midline, and 1 cm below the umbilicus. , Release of this hormone stimulates the mammary ducts and causes milk to be ejected from the breasts. The mother must wear a surgical mask when. Nursing Care Plan Table 1 Nursing Care Plan Assessment Nursing Diagnosis Outcomes Nursing Interventions Rational Evaluation Postpartum VS At risk for bleeding for a decrease in blood volume r/t postpartum period (Sparks & Taylor, 2014). Assessment: difficulty locating fundus; soft or boggy fundus; location of fundus above expected level; excessive lochia, especially bright red; and expulsion of an excessive number of clots. Mother and/or partner may be instructed to massage fundus. Administer: Straight catheterization if unable to void Medications as ordered Stool softener if ordered Consistency is recorded as "fundus firm with massage" or "fundus boggy. uterus large and boggy. If the fundus is not firm (boggy), fundal massage is indicated [17]. These patients often require general anesthesia as reduction is extremely. Fundus descends about 1 fingerbreadth or 1 cm daily ? Descends into pelvis on 10 th day, can no longer be palpated ? Returns to pre-preg size If episiotomy - scared will hurt or tear sutures with BM ? Nursing interventions may help prevent, relieve ? If C/S, clear liq till bowel sounds, then solid food. OB HESI 2 TEST BANKLATEST : ASSURED 100% SATISFACTIONS } BEST DOCUMENT FOR YOUR EXAMOB HESI 2 TEST BANK Which nursing intervention is most helpful in relieving postpartum uterine contractions or afterpains? a. A soft or boggy fundus isn't contracting well due to such factors as a full bladder or retained pieces of placenta and places the postpartum woman at risk for hemorrhage. Assess and record the type, amount, and site of the bleeding; Count and weigh perineal pads and if Assess the location of the uterus and degree of the contractility of the uterus/ Massage boggy uterus using one hand and place the second hand above the symphysis pubis. Options B and D: Elevating the clients legs and encouraging the client to void will not assist in managing. NURS 2130 Pediatrics Final 2020 1. Understanding that a boggy fundus and bladder distension can lead to uterine atony and ultimately PPH is very important because not only is it a possibility for all postpartum women but PPH is a potentially life threatening condition that requires immediate identification and intervention. To notify the patients midwife or physician b. in Fundus section Intervention Infection Nursing assessment Refer to Intervention Infection in Fundus section. Lochia normal. For nurses considering advancement, nursing interventions are a crucial concept to master. Safety nursing interventions include actions that maintain a patient's safety and prevent injuries. Myometrial contractions are vital to safeguard against excessive (and, potentially fatal) blood loss. Page 410 of book. In these examples, the measurement of outcomes includes behavioral indicators (in italics) as well as physiologic and organizational ones. the first intervention is to massage the fundus until it is firm and to express clots that may have accumulated in the uterus. During a postpartum assessment, the nurse notes that the uterus is midline and boggy. Indicative of uterine atony (loss of uterine musculature), if not corrected, results in PP Engorgement is when the breast is not being emptied enough d/t baby not nursing rigorously enough, separation from baby, not nursing enough. A nurse is preparing to assess the uterine fundus of a client in the immediate postpartum period. Apr 26, 2018 - Explore Jamie Ferguson's board "Awesome" on Pinterest. The first is the assessment, in which the nurse what are nursing responsibilities or nursing interventions for wound dressing? please help me. NR327 Exam 2 Review Questions #9 Care of the High-Risk Mother Newborn & Family With Special Needs aka Postpartum Maternal Complications 28 2/5/2019 9 NR327 Exam 2 Review Questions #9 Care of the High-Risk Mother Newborn & Family With Special Needs aka Postpartum Mater… 9 NR327 Exam 2 Review Questions #9 Care of the High-Risk Mother Newborn & Family With Special Needs aka. Medical and nursing interventions. Fundus is to the right. Uterine involution normal and uterus is not tender. Her lochial flow is profuse, with two plum-sized clots. massage the fundus, if boggy, until firm (do not over massage, this fatigues the muscle). )Boggy, midway between the umbilicus and symphysis pubis C. How do you document fundal height? 6. Nursing care plan/implementation: a. in Fundus section Intervention Infection Nursing assessment Refer to Intervention Infection in Fundus section. RNSG 2203 OB_Questions_for_HESI. Fundus is slightly boggy but firms with massage at 2 finger breadths above umbilicus, and is deviated to the right She also has moderate lochia and she isn’t moving around too much Lightly massage the fundus in a circular motion if boggy. notify the doctor 2. Rationale: Most of the nursing interventions during the postpartum period are directed toward helping the mother successfully adapt to the parenting role. Recovery and Care After Delivery. allnurses is a Nursing Career & Support site. Signs of uterine atony include a boggy uterus, a fundus that is higher than expected upon palpation, and excessive lochia. Which of the following must the nurse include in her discharge teaching regarding the vaccine? a. Document the sequence of events during the simulation (i. * Patient’s fundus was firm and located at the umbilicus as would be expected. (a) Explain condition and treatment. Assessment: difficulty locating fundus; soft or boggy fundus; location of fundus above expected level; excessive lochia, especially bright red; and expulsion of an excessive number of clots. Fundus 1 fingerbreadth below the umbilicus On postpartum day 1, the fundus should normally be 1 fingerbreadth below the umbilicus. Encourage the mother to empty her bladder before she breastfeeds. The mother must wear a. The Nursing Interventions Classification (NIC) is a care classification system which describes the activities that nurses perform as a part of the planning phase of the nursing process associated with the creation of a nursing care plan. On last assessment fundus was still soft & boggy. notify the doctor 2. What instruction needs to be given before palpating her bladder? 5. An empty bladder will allow the uterus to contract more efficiently and decreases the discomfort. Call the physician. See full list on myamericannurse. Patient will receive adequate screening/mo nitoring to alert clinicians of existing risk factors for bleeding. This is a joyous time, but it’s also a period of. Signs of uterine atony include a boggy uterus, a fundus that is higher than expected upon palpation, and excessive lochia. This video provides an overview of Chronic Obstructive Pulmonary Disease (COPD) interventions for care. Massage the fundus until it is firm If the uterus is not contracted firmly. In these examples, the measurement of outcomes includes behavioral indicators (in italics) as well as physiologic and organizational ones. Nursing Care Plan Table 1 Nursing Care Plan Assessment Nursing Diagnosis Outcomes Nursing Interventions Rational Evaluation Postpartum VS At risk for bleeding for a decrease in blood volume r/t postpartum period (Sparks & Taylor, 2014). Start learning today for free!. Indicative of uterine atony (loss of uterine musculature), if not corrected, results in PP Engorgement is when the breast is not being emptied enough d/t baby not nursing rigorously enough, separation from baby, not nursing enough. (a) Explain condition and treatment. What is the first thing you do? 1. The process that results in the rapid healing of the birth canal and the return of the uterus and all systems to or almost to the pre-pregnant state. Note that massaging a hard, contracted uterus can actually impede detachment of the placenta and With a boggy uterus, continue to massage and administer uterotonics to increase uterine contraction. Fundus descends about 1 fingerbreadth or 1 cm daily ? Descends into pelvis on 10 th day, can no longer be palpated ? Returns to pre-preg size If episiotomy - scared will hurt or tear sutures with BM ? Nursing interventions may help prevent, relieve ? If C/S, clear liq till bowel sounds, then solid food. The client has just started her third trimester of pregnancy. Describe the 3 stages of lochia and the time period for each. Learn more about nursing interventions, the NIC system and more. This is a joyous time, but it’s also a period of. After 12 hrs you could feel it back in the umbilicus again. She is a G2 P2002, delivered a 4 kg baby boy at 41 1/7 weeks gestation. What does it mean that the fundus is “deviated to the right of midline?” (p 428) What are Abigail’s 3 risk factors for uterine atony that could lead to a postpartum hemorrhage? What RN interventions are needed to firm up a boggy uterus and decrease the bleeding?. The top of the uterus is called the fundus, right after giving birth its felt half way between the symphysis pubis and the umbilicus. docx OB Questions for HESI 1. Our members represent more than 60 professional nursing specialties. (5) Nursing interventions. Massage the fundus until it is firm If the uterus is not contracted firmly. The term describes any action nurses may take to improve the health and comfort of their. Medically reviewed by Robin Madell. A comprehensive database of more than 16 obstetrical nursing quizzes online, test your knowledge with obstetrical nursing quiz questions. 05% of deliveries). bimanual uterine compression massage is performed by placing one hand in the vagina and pushing against the body of the uterus while the other hand. Immediately palpate uterine fundus and confirm if contracted. Nursing intervention and outcomes research using true experimental designs are mentioned briefly below. The postpartum nursing diagnosis is considered to be carried out in case if patient is undergoing the postpartum depression. (5) Nursing interventions. The process that results in the rapid healing of the birth canal and the return of the uterus and all systems to or almost to the pre-pregnant state. if soft/boggy or displaced perform: fundus. Cupping the dominant hand around the fundus and placing the other hand just above the pubic symphysis to support the lower uterine segment, the attendant gently massages the uterine fundus. monitor patient's vital signs every 15 minutes until stable. (d) Prevent bladder distention. The Fundus Skills and Assessment Trainer features the normal anatomy of the status-post or post-partum female abdomen designed for training fundus assessment and massage skills. Assess and record the type, amount, and site of the bleeding; Count and weigh perineal pads and if Assess the location of the uterus and degree of the contractility of the uterus/ Massage boggy uterus using one hand and place the second hand above the symphysis pubis. Auscultate bowel sounds and inquire daily about BMs. Understanding that a boggy fundus and bladder distension can lead to uterine atony and ultimately PPH is very important because not only is it a possibility for all postpartum women but PPH is a potentially life threatening condition that requires immediate identification and intervention. Boggy uterus: massage and assess trickling from vagina and urinary retention Fundus palpation, normal finding postpartum day 1: firm on palpation, 1 – 2 fingerbreadths below the umbilicus Pain assessment: accurate indicator - patient’s description of pain Phlebitis in one leg post-Cesarean, apply SCD only to uninvolved leg. Teach the patient how to apply graduate compression stockings and encourage the use of sequential compression stockings when in bed. Fourth stage of labor/Assessment/Fundus 1) After childbirth why is it critical that the uterine fundus stay well contracted? 2) Palpate fundus frequently for the next,,,,? 3) Fundus located? 4) Palpate fundus but do not massage it unless 5) What does boggy uterus indicate?. Options B and D: Elevating the clients legs and encouraging the client to void will not assist in managing uterine atony. Fundus gradually descends into pelvic cavity, and by ninth postpartum day should no longer be palpable (1 cm or 1 finger-breadth qd).