Yani is a 32-year-old female who just had a 6lb., 8 oz. baby boy eight hours prior to your shift.

QUESTION

Yani is a 32-year-old female who just had a 6lb., 8 oz. baby boy eight hours prior to your shift.

She had her baby with a vaginal delivery and did not have vaginal tears or require an episiotomy.

She has a saline loc in her right hand to keep the vein opened.

She is accompanied by her

husband with her baby at the bedside.

You have just started your nightshift are preparing to do

her vital signs.

You do her vital signs and note they are the following: Temp: 36, BP: 70/50,

Pulse: 130, RR: 24, Pulse Ox: 88% room air.

You ask she tells you this.

She continues further

by saying “goodness, I am sweating sooo much, I am so embarrassed, can you help me change.”

4) Describe what normal findings would be for a fundus for Yani at this point and also

describe what nursing intervention would you have to initiate for a fundus that is abnormal

finding?

Explain the rationale for the intervention (0.5 for the normal finding, 0.5 for

nursing intervention to initated for abnormal fundus finding

ANSWER

Normal Findings for Fundus

At this point, eight hours after delivery, the fundus should be approximately at the level of the umbilicus, firm, and midline. The fundus should gradually decrease in size and tone as the uterus undergoes involution. The postpartum assessment of the fundus is crucial to monitor for any signs of excessive bleeding or retained placental tissue.

Nursing Intervention for Abnormal Fundus Finding

If the fundus is found to be boggy (soft), displaced from the midline, or above the expected level (e.g., higher than the umbilicus), it indicates uterine atony, which is a potential cause of postpartum hemorrhage. In such a case, the nursing intervention would be to perform fundal massage. This intervention involves using gentle but firm circular motions on the uterus to stimulate contractions and improve uterine tone.

Rationale for the Intervention

Fundal massage is a vital nursing intervention for a boggy or displaced uterus because it helps to prevent or control postpartum hemorrhage. By stimulating uterine contractions, the massage aids in reducing bleeding by compressing blood vessels at the placental site and promoting the expulsion of any retained placental fragments. Additionally, fundal massage helps the uterus to contract back to its normal size, promoting the process of involution. It is essential to address any abnormal findings promptly to prevent complications such as hemorrhage and ensure the well-being of the postpartum client.

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