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
Explanation
Choice A reason:
Expressions of excitement are an expected finding during the taking-in phase of maternal postpartum adjustment. This is the time of reflection for the woman because, within the 2 to 3-day period, the woman is passive and dependent on her healthcare provider or support person with some of the daily tasks and decision-making. The woman prefers to talk about her experiences during labor and birth and also her pregnancy. The taking-in phase provides time for the woman to regain her physical strength and organize her rambling thoughts about her new role.
Choice B reason:
Lack of appetite is not an expected finding during the taking-in phase of maternal postpartum adjustment. The woman is oriented primarily to her own needs and she primarily focuses on sleeping and eating. She may have increased appetite due to the energy expenditure during labor and delivery. Lack of appetite may indicate postpartum depression or other complications.
Choice C reason:
Eagerness to learn newborn care skills is not an expected finding during the taking-in phase of maternal postpartum adjustment. This is more characteristic of the taking-hold phase, which starts 2 to 4 days after delivery. The woman starts to initiate actions on her own and make decisions without relying on others. She starts to focus on the newborn instead of herself and begins to actively participate in newborn care.
Choice D reason:
Focus on the family unit and its members is not an expected finding during the taking-in phase of maternal postpartum adjustment. This is more indicative of the letting-go phase, which occurs when the woman finally accepts her new role and gives up her old role. This is the phase where postpartum depression may set in. Readjustment of the relationship is needed for an easy transition to this phase.
Correct Answer is A
Explanation
Choice A reason:
Stop breastfeeding. This is the correct answer because newborns and infants with galactosemia cannot metabolize galactose, a sugar found in milk and lactose-containing formulas, including breast milk. Galactose can build up in their blood and cause serious complications such as liver damage, cataracts, brain damage, and even death. Therefore, the therapeutic management for this newborn is to stop breastfeeding and switch to a soy or elemental formula that contains no galactose.
Choice B reason:
Add amino acids to the breast milk. This is incorrect because adding amino acids to breast milk will not prevent the accumulation of galactose in the newborn's blood. Amino acids are the building blocks of proteins, not sugars. Adding amino acids to breast milk will not change its galactose content or help the newborn metabolize it.
Choice C reason:
Substitute a lactose-containing formula for breast milk. This is incorrect because lactose is a disaccharide composed of glucose and galactose. Lactose-containing formulas will also expose the newborn to galactose, which they cannot break down. Lactose-containing formulas should be avoided in newborns and infants with galactosemia.
Choice D reason:
Give the appropriate enzyme along with breast milk. This is incorrect because there is no enzyme therapy available for galactosemia. Galactosemia is caused by a genetic defect in one of the enzymes involved in the breakdown of galactose, such as galactose-1-phosphate uridyltransferase (GALT), galactokinase (GALK), or uridine diphosphate galactose-4-epimerase (GALE). Giving an enzyme along with breast milk will not correct this defect or prevent the harmful effects of galactose accumulation.
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