Following delivery, the nurse's assessment reveals a soft, boggy uterus located above the level of the umbilicus. The appropriate intervention is:

Massage the fundus

Initiate measures that encourage voiding

Position the patient flat

Notify the doctor

Answer and Explanation

The Correct Answer is A

Massage the fundus. This is because massaging the fundus (the upper part of the uterus) can help the uterus contract and prevent excessive bleeding after delivery. A soft, boggy uterus indicates uterine atony, which is a failure of the uterus to contract sufficiently after childbirth.

Uterine atony is the most common cause of postpartum hemorrhage, which can be life-threatening if not treated promptly¹².

Choice B is not correct because initiating measures that encourage voiding is not the appropriate intervention for a soft, boggy uterus. A full bladder can interfere with uterine contractions and cause bleeding, so it is important to empty the bladder after delivery. However, this should be done after massaging the fundus.

Choice C is not correct because positioning the patient flat is not the appropriate intervention for a soft, boggy uterus. Positioning the patient flat can increase blood loss and reduce venous return. The patient should be positioned with the head slightly elevated and the legs flexed to improve blood circulation and prevent shock³.

Choice D is not correct because notifying the doctor is not the first intervention for a soft, boggy uterus. Notifying the doctor is important if bleeding persists or worsens despite massaging the fundus. The doctor may order medications or other treatments to stop the bleeding and prevent complications¹.

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Correct Answer is D

Explanation

Wash hands before touching each baby. This is because hand hygiene is the most effective way to prevent infection transmission in the nursery. Hand hygiene should be performed before and after every patient contact, as well as before and after wearing gloves or handling equipment. Hand hygiene can be done by washing hands with soap and water or using alcohol-based hand rubs.

Choice A is not correct because adjusting room temperature between 75°F and 80°F is not a measure to protect newborns from infection. The room temperature should be maintained within a comfortable range for newborns, but it does not affect infection risk.

Choice B is not correct because wearing a disposable gown when giving infant care is not a measure to protect newborns from infection. Disposable gowns are part of contact precautions, which are used for patients with known or suspected infections that can be transmitted by direct or indirect contact. They are not necessary for routine infant care.

Choice C is not correct because keeping the newborn dressed warmly is not a measure to protect newborns from infection. Keeping the newborn dressed warmly can help prevent heat loss and hypothermia, but it does not affect infection risk.

A. This can be related to cleaning her perineal area. Be more careful. B. The baby may have a problem. Let's schedule an appointment. C. If this continues, call us back. For now, just watch her. D. This can be from the sudden withdrawal of your hormones. It is not a cause for alarm.

Correct Answer is D

Explanation

This can be from the sudden withdrawal of your hormones. It is not a cause for alarm. This is because newborn female babies may have a little bloody vaginal discharge in their diapers due to the withdrawal of maternal hormones after delivery. This usually stops as the hormones return to normal levels. The nurse should reassure the mother that this is a normal and harmless phenomenon and does not require any treatment.

Choice A is wrong because the blood is not related to cleaning her perineal area. The nurse should not blame the mother for being careless.

Choice B is wrong because the baby does not need an appointment for this condition. The nurse should not alarm the mother unnecessarily.

Choice C is wrong because the mother does not need to watch her baby for this condition. The nurse should not leave the mother in doubt or anxiety.

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Following delivery, the nurse's assessment reveals a soft, boggy uterus located above the level of the umbilicus. The appropriate intervention is:

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Naxlex Comprehensive Predictor Exams

To protect newborns from infection while in the nursery, the nurse plans to:

Correct Answer is D

Explanation

A new mother of a newborn girl calls the clinic in a panic, concerned about the blood-tinged soiled diaper. What is the best response from the nurse?

Correct Answer is D

Explanation

Parents express concern about the milia on the face and nose of their baby. The nurse's most helpful response would be to instruct the parents to:

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A nurse is collecting data from a postpartum client and finds a large amount of lochia rubra with several clots on the client's perineal pad. Which of the following actions should the nurse take first?

Following delivery, the nurse's assessment reveals a soft, boggy uterus located above the level of the umbilicus. The appropriate intervention is:

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