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 B
Explanation
A. Oversupply of milk. This can lead to milk stasis and blockage, which can increase the risk of mastitis.
B. Gradual weaning of breastfeeding. Gradual weaning typically helps reduce the risk of mastitis because it allows the milk supply to decrease slowly and naturally without engorgement or blockage.
C. Infrequent, inconsistent feedings. This can lead to milk stasis and is a common cause of mastitis.
D. Cracks or fissures of the nipples. These can provide an entry point for bacteria, leading to infection and mastitis.
Correct Answer is ["A","B","D","E"]
Explanation
A. Tachypnea. Rapid breathing can indicate respiratory distress associated with heart failure.
B. Wheezes or rales. These are abnormal breath sounds indicating fluid in the lungs, which can occur with heart failure.
C. Bounding pulses. Bounding pulses are not typically associated with heart failure; weak pulses may be present due to poor perfusion.
D. Edematous. Edema can occur due to fluid retention, a sign of heart failure.
E. Difficulty feeding. Poor feeding can result from decreased cardiac output affecting systemic circulation and energy for feeding.
F. Increased comfort laying down. Children with heart failure often prefer sitting upright due to respiratory distress.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.