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 ["A","D","E"]
Explanation
A. Handwashing. Good hygiene is important to prevent the spread of the virus, especially after touching the lesions.
B. Gardasil injection. Gardasil is a vaccine for HPV, not HSV. It is not relevant for the management of herpes.
C. Penicillin. Penicillin is not effective against viral infections like herpes; antiviral medications such as acyclovir are used for treatment.
D. Use of barrier protection. Barrier methods such as condoms are crucial in reducing the risk of transmission of HSV-2 to sexual partners.
E. Perineal care of genital lesions. Proper care of lesions can help reduce discomfort and prevent secondary infections.
Correct Answer is []
Explanation
Complication: Otitis Media
Anatomical Changes:
- Small external ear structure: Infants born with a cleft palate often have smaller external ear structures, which can affect the drainage of fluids and increase the risk of infections.
- Horizontal eustachian tubes: Eustachian tubes in individuals with cleft palate are typically more horizontal than normal, impairing the drainage of fluid from the middle ear.
- Large tongue: A large tongue may obstruct the upper airway and interfere with normal swallowing and speaking functions.
Complication: Otitis Media
- Due to the anatomical changes associated with cleft palate, such as horizontal eustachian tubes and impaired drainage, individuals are prone to recurrent middle ear infections (otitis media). These infections can lead to fluid accumulation behind the eardrum, which can further impair hearing and potentially lead to more serious complications if untreated.
Priority Interventions:
- Ear drops (for otitis media): Ear drops containing antibiotics may be prescribed to treat bacterial infections in the middle ear, which are common in individuals with cleft palate.
- Rationale: Ear drops help to directly treat the infection in the ear canal and middle ear, reducing inflammation and preventing complications such as hearing loss or spread of infection.
- Corticosteroids (for inflammation): Corticosteroids may be used to reduce inflammation in the ear canal and middle ear, particularly in cases of severe otitis media.
- Rationale: Corticosteroids help to decrease swelling and inflammation, which can improve symptoms and aid in the healing process of the ear.
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