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 B
Explanation
A. The newborn with a heart rate of 154 beats/minute. This is within the normal range for a newborn, which is between 120-160 beats per minute.
B. The newborn with a respiratory rate of 72 breaths/minute. This is abnormal; the normal respiratory rate for a newborn is between 30-60 breaths per minute. A rate of 72 could indicate respiratory distress and requires prompt evaluation.
C. The newborn with a red raised capillary hemangioma on the left forearm. Capillary hemangiomas are common, benign vascular tumors that typically do not require immediate intervention.
D. The newborn with whitish, hardened nodules on the gums of the mouth. These are likely Epstein pearls, which are harmless cysts often seen in newborns and typically resolve on their own.
Correct Answer is C
Explanation
A. Implementing stress management workshops for employees in a workplace: This is an example of primary prevention, which aims to reduce the risk of mental health issues by promoting healthy behaviors and coping mechanisms.
B. Promoting mental health awareness and education in the community: This also falls under primary prevention, focusing on reducing the incidence of mental health issues through education and awareness.
C. Providing counseling and therapy to individuals with diagnosed mental health disorders: This represents tertiary prevention, which focuses on managing and mitigating the impact of existing mental health conditions to improve quality of life and prevent complications or deterioration.
D. Conducting mental health screenings in schools to identify students at risk for mental health issues: This is a form of secondary prevention, which involves early identification and intervention to prevent the progression of mental health issues.
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