A nurse is preparing to perform a fundal massage for a postpartum client who is experiencing uterine atony. In which order should the nurse plan to perform the following actions?
Ask the client to lie on her back and with her knees flexed.
Position one hand around the top of the client's fundus and one hand just above the client's symphysis pubis.
Rotate the upper hand to massage the client's uterus while using slight downward pressure to compress the fundus.
Observe the client's perineum for the passage of clots and the amount of bleeding.
The Correct Answer is A, B, C, D
The correct answer is A, B, C, D.
The nurse should plan to perform the following actions in this order:
A. Ask the client to lie on her back and with her knees flexed.
B. Position one hand around the top of the client’s fundus and one hand just above the client’s symphysis pubis.
C. Rotate the upper hand to massage the client’s uterus while using slight downward pressure to compress the fundus.
D. Observe the client’s perineum for the passage of clots and the amount of
bleeding.
Fundal massage is performed to stimulate uterine contractions and prevent
postpartum hemorrhage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A nurse should discontinue oxytocin if the client experiences uterine hyperkinesia, which is defined as more than 5 contractions in 10 minutes.
Choice B is not correct because contractions lasting 60 seconds are within the normal range.
Choice C is not correct because moderate variability of the fetal heart rate is a reassuring sign.
Choice D is not correct because nonrepetitive early decelerations are generally considered benign and do not require intervention.
Correct Answer is D
Explanation
Do not retract the foreskin to clean your baby’s penis during each diaper change.
The foreskin should not be retracted for cleaning during infancy.
Choice A is incorrect because you should clean around the umbilical cord stump with plain water and blot dry until it falls off naturally.
Choice B is incorrect because swaddling a baby tightly with their legs extended is not recommended.
Choice C is incorrect because a newborn should urinate at least six times a day.
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