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 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. The baseline FHR can be obtained via ultrasound or auscultation: True. The baseline fetal heart rate can be assessed using ultrasound or auscultation, which are standard methods.
B. The baseline FHR can be obtained during contractions: False. The baseline fetal heart rate should be obtained in the absence of uterine contractions because contractions can temporarily alter the heart rate, making it difficult to determine the true baseline.
C. The baseline FHR is normal between 110-160 bpm: True. This is the accepted normal range for baseline fetal heart rates.
D. The baseline FHR is assessed over a 10-minute period: True. The baseline is typically assessed over a 10-minute window to account for variability and provide an accurate average.
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