A nurse is assisting in the care of a client who had a vaginal birth 2 hours ago. Which of the following actions should the nurse take? (Select all that apply.)
Document fundal height
Observe the lochia during palpation of fundus
Massage a firm fundus
Determine whether the fundus is midline
Administer terbutaline if the fundus is boggy
Correct Answer : A,B,D
Choice A:
Document fundal height. This is a correct action because the nurse should monitor the involution of the uterus by measuring the fundal height and comparing it to the expected level. The fundus should descend about one fingerbreadth (1 cm) per day after delivery and be at the level of the umbilicus immediately after birth.
Choice B:
Observe the lochia during palpation of the fundus. This is a correct action because the nurse should assess the amount, color, and consistency of the lochia (vaginal discharge) during the fundal massage. The lochia should change from rubra (red) to serosa (pink) to alba (white) over time and not increase in amount or revert to a previous stage.
Choice C:
Massage a firm fundus. This is an incorrect action because a firm fundus indicates adequate uterine contraction and involution. Massaging a firm fundus can cause discomfort and bleeding for the client. The nurse should only massage a boggy (soft) fundus to stimulate contraction and prevent hemorrhage.
Choice D:
Determine whether the fundus is midline. This is a correct action because the nurse should check if the fundus is deviated to either side, which may indicate a full bladder. A full bladder can interfere with uterine contraction and cause bleeding or infection. The nurse should assist the client to void if the fundus is not midline.
Choice E:
Administer terbutaline if the fundus is boggy. This is an incorrect action because terbutaline is a tocolytic drug that relaxes the uterine muscle and inhibits contractions. It is used to stop preterm labor, not to treat postpartum hemorrhage. The nurse should administer oxytocin or other uterotonic drugs if the fundus is boggy and does not respond to massage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","E","F"]
Explanation
Choice A reason:
Moro is a newborn reflex that occurs when the baby is startled by a loud sound or movement. The baby will cry, throw back his or her head, and then pull his or her limbs into the body. This reflex lasts until the baby is about 2 months old.
Choice B reason:
Rooting is a newborn reflex that starts when the corner of the baby's mouth is stroked or touched. The baby will turn his or her head and open his or her mouth to follow and root in the direction of the stroking. This helps the baby find the breast or bottle to start feeding. This reflex lasts about 4 months.
Choice C reason:
Gag is a newborn reflex that prevents the baby from choking on foreign objects. The baby will cough, gag or spit out anything that touches the back of the throat or the roof of the mouth. This reflex is present throughout life.
Choice D reason:
Running is not a newborn reflex. It is a voluntary movement that develops later in childhood. Choice E reason:
Babinski is a newborn reflex that occurs when the sole of the foot is stroked from heel to toe. The baby will fan out and curl up the toes and twist the foot inward. This reflex lasts until the baby is about 12 months old.
Choice F reason:
Stepping is a newborn reflex that occurs when the baby is held upright with his or her feet touching a solid surface. The baby will appear to take steps or dance. This reflex lasts about 2 months.
Choice G reason:
The crawling reflex is a developmental milestone observed in infants around 6-8 months of age. It involves the baby moving on their hands and knees, often starting with a belly-crawling motion. Unlike newborn reflexes, this skill is learned and requires muscle coordination and strength.
Choice H reason:
Standing with support is a developmental milestone typically achieved by infants around 9-12 months. In this skill, the baby pulls themselves up to a standing position while holding onto furniture or a caregiver’s hands. It is a learned behavior reflecting increased muscle strength and balance, distinct from newborn reflexes.
Choice I reason:
The pincer grasp is a fine motor skill that usually develops between 8-12 months. It involves the baby using the thumb and index finger to pick up small objects. This ability is not a reflex but a learned skill that demonstrates improved hand-eye coordination and dexterity.
Correct Answer is B
Explanation
Choice A reason:
This is incorrect because TTN usually resolves within 24 to 72 hours of birth and does not require a long stay in the NICU.
Choice B reason:
This is correct because TTN is more common in babies born by cesarean section without labor, as they do not have the hormonal changes that help clear the fetal lung fluid.
Choice C reason:
This is incorrect because breastfeeding is not contraindicated in babies with TTN, unless they have severe respiratory distress or need continuous positive airway pressure (CPAP) support.
Choice D reason:
This is incorrect because TTN does not cause chronic lung disease or require oxygen therapy at home. Most babies with TTN only need supplemental oxygen for a few days until their breathing improves.
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