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 D

Explanation

A. Reprimand the client about the potential damage that has occurred due to overexercising her body: Reprimanding is likely to increase feelings of guilt and shame, which can exacerbate the disorder. A supportive and empathetic approach is more beneficial.
B. Praise the client for looking at herself in a mirror: This could reinforce a negative preoccupation with body image, which is a significant aspect of anorexia nervosa. Encouraging healthy coping mechanisms is more appropriate.
C. Restrict the client from being weighed: While it is important to manage weight monitoring carefully, outright restriction without addressing the underlying issues can increase anxiety and resistance to treatment.
D. Ask the client to agree to talk to a nurse whenever she feels the urge to exercise: This helps the client develop healthier coping strategies and provides support in managing the urge to overexercise, promoting therapeutic engagement.

A. Use physical restraints during severe outbursts to ensure safety. B. Assign daily chores that are challenging to encourage discipline. C. Encourage solitary play to reduce social stressors. D. Put into practice consistent consequences for rule-breaking behavior.

Correct Answer is D

Explanation

A. Use physical restraints during severe outbursts to ensure safety: Restraints should only be used as a last resort and are not an effective or ethical primary strategy for managing behavior in children with ODD.
B. Assign daily chores that are challenging to encourage discipline: Assigning overly challenging chores may lead to frustration and non-compliance, exacerbating behavioral issues rather than helping.
C. Encourage solitary play to reduce social stressors: Isolating the child may worsen feelings of exclusion and does not address the need for social skills development and appropriate behavior in social contexts.
D. Put into practice consistent consequences for rule-breaking behavior: Consistency in consequences helps the child understand boundaries and the importance of following rules, which is crucial for managing behavior in ODD.

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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

A nurse is caring for a client diagnosed with anorexia nervosa and over exercises to avoid gaining weight. Which of the following should be the appropriate action by the nurse?

Correct Answer is D

Explanation

A 9-year-old client with oppositional defiant disorder (ODD) has been referred to a child psychologist due to frequent outbursts and defiant behavior at home and school. Which of the following interventions should the nurse prioritize to help manage the child's behavior effectively?

Correct Answer is D

Explanation

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