Question

A client is transferred from the operating room to the postpartum unit following a cesarean section for fetal distress. When the nurse performs the postpartum assessment, the client complains of pain and asks the nurse not to palpate the fundus. Which is the appropriate nursing action? A. Ask a more experienced nurse to palpate the fundus. B. Palpate the fundus anyway while avoiding the incision area. C. Avoid palpating the fundus as long as the vital signs are stable. D. Explain the need for fundal palpation and then palpate the fundus from the side.

Short answer

The appropriate nursing action is to explain the need for fundal palpation (D), which is crucial for assessing the risk of hemorrhage, and then to carefully palpate the fundus from the side to minimize discomfort.

Step-by-step solution

Understanding the Situation

Recognize that the patient is post-cesarean and is in pain, which could hinder the fundus palpation. Assess the importance of fundal palpation in postpartum care and its relation to patient comfort.

Considering the Options

Evaluate the four given options critically. Option A suggests delegating the task to a more experienced nurse, which does not address the patient's pain. Option B involves palpating the fundus despite the patient's complaint of pain, which may not be in line with respecting patient's discomfort. Option C suggests avoiding fundal palpation if vital signs are stable, which could miss critical assessments post-surgery. Option D involves explaining why fundal palpation is necessary and then carefully performing the assessment.

Choosing the Best Action

Select the option that respects the patient's complaint while also ensuring important assessment is performed. Explaining the procedure and ensuring the patient understands its importance offers a balance between clinical necessity and patient care.

Making a Judgment Based on Nursing Principles

Apply principles of patient-centered care, informed consent, and clinical judgment. It is crucial for the patient to understand the purpose of palpating the fundus, which is to check for uterine atony that could lead to hemorrhage.

Key concepts

Fundal Palpation

The process of fundal palpation is a key component in postpartum nursing care. It is conducted to assess the firmness and position of the uterus following delivery to ensure that it is contracting appropriately and returning to its pre-pregnancy size and location. This is crucial in identifying uterine atony, a condition which can lead to excessive bleeding and other complications.

Fundal palpation should be performed gently and with care. The nurse must inform the patient about the necessity for this examination to monitor healing and prevent potential adverse outcomes, especially after a cesarean section. Explaining the procedure can alleviate fear and ensure cooperation. If the patient is in pain, as is often the case following a cesarean, the nurse should take measures to minimize discomfort, such as offering pain relief before the palpation and ensuring a gentle approach away from the incision site.

Cesarean Section Recovery

Recovery from a cesarean section involves special considerations, as it is a major abdominal surgery. A patient's pain and discomfort need to be managed effectively while also monitoring for signs of infection or excessive bleeding. Nurses play a critical role in assisting patients through this healing process, ensuring that patients are able to rest, providing appropriate pain management, and guiding them through post-surgical care practices.

Pain management often includes medication, but it also involves supporting the patient in finding comfortable positions and mobilizing as soon as safely possible to promote circulation and healing. It's also important for the nursing staff to understand and respect the patient's pain threshold and work collaboratively with them to ensure a recovery that is as comfortable as possible.

Patient-Centered Care

Patient-centered care is a cornerstone of modern nursing practice and involves considering the patients' preferences, values, and needs in all aspects of their care. This approach encompasses not only physical health but also emotional and psychological well-being. Communication is a critical element, as it involves actively listening to the patient's concerns and involving them in decisions about their care.

In the context of postpartum care, especially after a cesarean section, respecting the patient's wishes, such as the desire not to have the fundus palpated due to pain, is balanced against the clinical need for the examination. A patient-centered approach would involve explaining the reasons for necessary procedures and possible alternatives, providing reassurance, and seeking consent. This respectful collaboration helps in building trust and ensures patient cooperation, contributing to better outcomes and patient satisfaction.