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

Administer Oxytocin IV per MD orders

Notify the healthcare provider

Document the fundal height and consistency

Massage the fundus until it firms

Answer and Explanation

The Correct Answer is D

A. Administer Oxytocin IV per MD orders. This may be done after attempting fundal massage to help firm the uterus, but massage is the first step.
B. Notify the healthcare provider. This would be done if the fundus does not respond to massage or if excessive bleeding continues, but not before attempting to firm the fundus.
C. Document the fundal height and consistency. Documentation is important but should occur after addressing the immediate issue of a soft fundus to prevent hemorrhage.
D. Massage the fundus until it firms. The immediate action should be to massage the uterus to promote contraction and reduce bleeding. A soft, spongy uterus indicates uterine atony, which can lead to hemorrhage.

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Correct Answer is A

Explanation

A. This position prevents stomach juice from going into the lungs. Elevating the head helps prevent reflux of stomach contents into the trachea and lungs, which can lead to aspiration pneumonia.
B. This position allows food to be easily digested by the stomach. The position primarily focuses on respiratory protection, not digestion.
C. This position helps my baby breathe better by opening the lungs. While elevation can aid breathing, it's primarily to prevent aspiration rather than improving respiratory function.
D. This position keeps pressure off the stomach. It's not primarily about relieving pressure but rather preventing aspiration.

A. Playing on the backyard swings and running around outside are exercises our child will really enjoy B. Three to four times a day we will perform chest therapy and postural drainage on our child C. A high protein, high calorie diet may need to be supplemented with a high-calorie formula D. Pancreatic enzymes will not be necessary if our child has a good appetite and regular bowel movements

Correct Answer is D

Explanation

A. Playing on the backyard swings and running around outside are exercises our child will really enjoy. Encouraging physical activity is beneficial as it helps with lung function and overall health.
B. Three to four times a day we will perform chest therapy and postural drainage on our child. This is correct and necessary to help clear mucus from the lungs.
C. A high protein, high-calorie diet may need to be supplemented with a high-calorie formula. This is important for meeting the nutritional needs of children with cystic fibrosis due to their higher caloric requirements.
D. Pancreatic enzymes will not be necessary if our child has a good appetite and regular bowel movements. This is incorrect; children with cystic fibrosis typically need pancreatic enzyme supplements with every meal and snack to aid digestion, regardless of appetite or bowel regularity.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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