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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
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.
Correct Answer is B
Explanation
A. O negative blood type. This is significant for Rh incompatibility if the fetus is Rh-positive, but it is managed through routine prenatal care and does not require immediate intervention at 36 weeks.
B. Blood pressure 144/94 mmHg in left arm. This finding is concerning because it may indicate the development of preeclampsia, which requires immediate medical attention due to the potential risks to both the mother and fetus.
C. Positive rubella serum antibody titer. A positive titer indicates immunity to rubella, which is a good finding in pregnancy and not a concern.
D. Copious leukorrhea. This is common in late pregnancy and typically not a cause for concern unless it is accompanied by signs of infection or rupture of membranes.
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