The nurse assesses a boggy uterus with the fundus above the umbilicus and deviated to the side. The nurse should next assess:
A.
Blood pressure
B.
Amount of lochia
C.
Fulness of the bladder
D.
Level of pain
The Correct Answer and Explanation is:
The correct answer is C. Fullness of the bladder.
Explanation:
After childbirth, the uterus, or fundus, should be firm, midline, and positioned at or near the level of the umbilicus. A “boggy” uterus refers to one that is soft and not well contracted. This condition can lead to postpartum hemorrhage, which is a significant concern in the immediate postpartum period. When the fundus is higher than expected (above the umbilicus) and deviated to one side, typically to the right, the most common cause is a distended bladder.
Bladder Distension and Uterine Involution:
A full bladder can push the uterus out of its normal position, making it difficult for the uterus to contract effectively. This displacement is usually to the right side because the bladder, when full, tends to push the uterus in that direction. A poorly contracted uterus increases the risk of postpartum hemorrhage because it prevents the uterine blood vessels from being compressed, which is necessary to stop the bleeding at the placental site.
Immediate Nursing Actions:
The nurse’s priority should be to assess the fullness of the bladder. If the bladder is distended, the nurse should assist the mother in emptying it, either by encouraging her to void naturally or by using catheterization if necessary. Once the bladder is empty, the nurse should reassess the uterus. Typically, after the bladder is emptied, the uterus will return to the midline, become firm, and move closer to the umbilicus.
Other Assessments:
- Blood Pressure (Option A): While assessing blood pressure is important, it is not the immediate priority in this scenario. Blood pressure monitoring is essential to identify signs of shock or other complications, but it will not address the root cause of a boggy, displaced uterus.
- Amount of Lochia (Option B): Assessing lochia is important to monitor bleeding, but if the uterus remains boggy and displaced, the bleeding could worsen. Addressing the bladder fullness first can help reduce excessive lochia.
- Level of Pain (Option D): While assessing pain is also crucial, it does not directly address the cause of the uterine deviation and bogginess. Pain may be related to uterine atony or bladder distension, but relieving the bladder distension will often alleviate discomfort and improve uterine tone.
In summary, assessing and addressing bladder fullness is the priority in this scenario to prevent postpartum hemorrhage and promote effective uterine contraction.