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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Have you passed any clots? This is important to assess for potential postpartum hemorrhage, which can be indicated by passage of large clots.
B. Do you have to go to the bathroom? This does not directly address the issue of excessive bleeding.
C. When was the last time you changed your pad? This provides information about the amount of bleeding but does not address clotting.
D. Are you having any cramping? Cramping is common postpartum but does not directly assess for hemorrhage.
Correct Answer is D
Explanation
A. "Apply cold compresses when your child expresses pain." Cold can cause vasoconstriction, which may precipitate a sickle cell crisis by reducing blood flow to the extremities, thus increasing the risk of sickling of red blood cells. Warm compresses are recommended to help alleviate pain by promoting blood flow.
B. "Restrict outdoor play activity to 1 hour per day." While it's important to monitor physical activity to avoid overexertion, restricting outdoor play to a specific time frame without considering other factors like hydration and rest isn't the right approach. Physical activity is important but should be balanced with adequate hydration and rest.
C. "Monitor your child's temperature daily." While monitoring temperature is important, it isn't specifically critical on a daily basis unless there is a suspicion of infection. The primary focus should be on hydration and recognizing signs of infection.
D. "Offer fluids to your child multiple times every day." Hydration is crucial for children with sickle cell anemia as it helps to prevent sickling of cells by maintaining good blood flow and preventing dehydration, which can trigger a crisis.
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