A nurse is assessing the fundus of a postpartum client one day after delivery and notes that the fundus is soft and spongy.
Which is the first nursing intervention to perform?

Massage the fundus until it firms.

Notify the healthcare provider.

Document the fundal height and consistency.

Administer Oxytocin V as per MD orders.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Massaging the fundus is the first-line intervention when the fundus is soft and spongy, indicating uterine atony. Massage stimulates uterine contractions, reducing postpartum bleeding and restoring uterine tone, which is crucial to prevent hemorrhage.

Choice B rationale

Notifying the healthcare provider is necessary if initial interventions fail to address uterine atony. However, immediate action such as massaging the fundus should be taken first to minimize bleeding risks and stabilize the client.

Choice C rationale

Documenting fundal height and consistency is important but not an immediate intervention. Recording observations without addressing the atony fails to prevent potential complications like postpartum hemorrhage, which requires prompt and active management.

Choice D rationale

Administering Oxytocin as per MD orders aids uterine contraction but is not the first intervention. Massaging the fundus provides immediate mechanical stimulation to contract the uterus, a vital step before pharmacological measures are considered.

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Correct Answer is B

Explanation

Choice A rationale

A positive rubella serum antibody titer indicates immunity to rubella infection, which is protective during pregnancy. It is not an abnormal finding and does not require immediate reporting. Rubella immunity is important to prevent congenital rubella syndrome in the fetus, a severe condition causing defects such as deafness or cardiac anomalies.

Choice B rationale

Blood pressure of 144/94 mmHg is elevated and indicates gestational hypertension, which could progress to preeclampsia if not managed. Preeclampsia can lead to complications such as eclampsia, placental abruption, or maternal and fetal mortality. Normal blood pressure during pregnancy is less than 140/90 mmHg, making this finding critical to report.

Choice C rationale

Copious leukorrhea is a common physiological change in pregnancy due to increased estrogen levels and vascularity. It is usually benign and protective, preventing infections by maintaining a mildly acidic environment in the vagina. This finding does not warrant immediate concern unless associated with infection symptoms.

Choice D rationale

An O-negative blood type requires administration of Rh immunoglobulin to prevent Rh isoimmunization, but this is routinely managed in pregnancy. It is not an urgent issue unless there are concerns about fetomaternal hemorrhage or alloimmunization, which could harm an Rh-positive fetus.

A. Accurately measure intake and output. B. Provide for several periods of uninterrupted rest. C. Maintain a thermoneutral environment. D. Encourage periods of bonding. E. Use an incentive spirometer 10 times every hour.

Correct Answer is ["C"]

Explanation

Choice A rationale

Assessing the baseline fetal heart rate (FHR) over a 10-minute period ensures accurate measurement by capturing rate fluctuations due to fetal activity or maternal factors. This duration is a standardized method to establish a representative baseline. Variability is excluded during this time, focusing on a stable resting rate.

Choice B rationale

Baseline FHR can be obtained using ultrasound or auscultation, both being reliable non-invasive methods for assessing fetal well-being. These tools accurately detect cardiac activity and provide real-time data, allowing consistent monitoring during labor.

Choice C rationale

Baseline FHR cannot be obtained during contractions due to transient accelerations or decelerations caused by uterine compression. These changes do not represent the resting heart rate. Accurate baseline assessments require a period without uterine activity to avoid skewed results.

Choice D rationale

A normal FHR of 110-160 bpm indicates adequate oxygenation and neural regulation. This range reflects the fetal cardiovascular system's ability to adapt to in utero conditions. Values outside this range might suggest hypoxia, infection, or other abnormalities.

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A nurse is assessing the fundus of a postpartum client one day after delivery and notes that the fundus is soft and spongy.Which is the first nursing intervention to perform?

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A nurse is assessing the fundus of a postpartum client one day after delivery and notes that the fundus is soft and spongy.
Which is the first nursing intervention to perform?