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. Administer parenteral antibiotics. The primary concern with premature rupture of membranes (PROM) is the risk of infection, so administering antibiotics is crucial to prevent infection in both the mother and fetus.
B. Prepare for delivery. Without signs of labor, the focus is on preventing infection and monitoring, not immediate delivery.
C. Provide emotional support. While important, the priority intervention is preventing infection.
D. Assess cervical dilation every 6 hours. Routine cervical checks are not typically necessary unless there are signs of labor or other indications.
Correct Answer is ["A","C","E"]
Explanation
A. I'll expect the plastic ring to fall off by itself within a week. This is correct; the Plastibell ring typically falls off within 5-8 days.
B. I'll apply petroleum jelly to his penis with diaper changes. Incorrect for Plastibell, because the plastic ring itself protects the site, and petroleum jelly can interfere with healing.
C. I'll make sure his diaper is loose in the front. This helps avoid pressure and irritation on the circumcised area.
D. I'll wash his penis with warm water and mild soap each day. Incorrect; the area should be kept clean but only water should be used to avoid irritation.
E. I'll call the doctor if I see any bleeding. Any significant bleeding should be reported to the healthcare provider immediately.
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