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","E"]
Explanation
Choice A:
Tremors. This is a sign of hypoglycemia in a newborn because low blood sugar can cause shakiness or jitteriness in the muscles. •
Choice B:
Lethargy. This is a sign of hypoglycemia in a newborn because low blood sugar can cause low energy, poor feeding, or lack of interest in eating.
Choice C:
Hunger. This is not a sign of hypoglycemia in a newborn because low blood sugar can actually reduce the appetite or cause feeding difficulties.
Choice D:
Jaundice. This is not a sign of hypoglycemia in a newborn because jaundice is caused by high levels of bilirubin in the blood, not low levels of glucose.
Choice E:
Weak cry. This is a sign of hypoglycemia in a newborn because low blood sugar can affect the vocal cords and the respiratory system, causing a weak or high-pitched cry.
Correct Answer is C
Explanation
Choice A reason:
Hypertonia is not a characteristic of a preterm infant, but rather of a post-term infant. Hypertonia means increased muscle tone or stiffness, which is more common in infants who are overdue. Preterm infants have poor muscle tone and less subcutaneous fat.
Choice B reason:
Long toenails are also not a characteristic of a preterm infant but of a post-term infant. Long toenails indicate that the infant has grown beyond the expected gestational age. Preterm infants have short and brittle nails.
Choice C reason:
Lanugo is a characteristic of a preterm infant. Lanugo is fine, downy hair that covers the body of the fetus. It usually disappears by the 36th week of gestation, but preterm infants may still have it at birth.
Choice D reason:
Dry skin is not a characteristic of a preterm infant but of a post-term infant. Dry skin indicates that the infant has lost moisture and subcutaneous fat due to prolonged exposure to the amniotic fluid. Preterm infants have thin and transparent skin that may be covered by vernix caseosa, a white, cheesy substance that protects the skin from the amniotic fluid.
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