Difficulty: Medium
Average Score: 82%
Simulated
Passage / Scenario
A client who had a vaginal delivery 2 hr agoA nurse is caring for a client who had a vaginal delivery 2 hr ago. Which of the following actions should the nurse anticipate in the care of this client? (Select all that apply.)
Correct answer
B,C,D,E
Rationale
B: Checking if the fundus is midline ensures proper uterine positioning. C: Documenting fundal height tracks involution. D: Observing lochia monitors for excessive bleeding. E: Methylergonovine is indicated for a boggy uterus to promote contractions. A is incorrect as massaging a firm fundus is unnecessary.