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

This is because lochia rubra is the first stage of lochia, the vaginal discharge after giving birth. It comprises blood, shreds of fetal membranes, decidua, vernix caseosa, lanugo, and membranes. It is red in color because of the large amount of blood it contains. It lasts 1 to 4 days after birth.

Choice A is not correct because lochia alba is the last stage of lochia. It is whitish or yellowish-white in color and contains fewer red blood cells and more leukocytes, epithelial cells, cholesterol, fat, mucus, and microorganisms. It lasts from the second through the third to sixth weeks after delivery.

Choice B is not correct because there is no such thing as lochia normal. Lochia has three stages: lochia rubra, lochia serosa and lochia alba.

Choice C is not correct because lochia serosa is the second stage of lochia. It is brownish or pink in color and contains serous exudate, erythrocytes, leukocytes, cervical mucus, and microorganisms. It lasts for 4 to 12 days after delivery.

A. Sucking B. Grasp C. Tonic neck D. Rooting

Correct Answer is D

Explanation

Rooting. The rooting reflex is a primitive neonatal reflex that helps the baby find the breast or bottle to start feeding. 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 reflex lasts about 4 months.

Choice A. Sucking is not the correct answer because it is a different reflex that starts when the roof of the baby's mouth is touched, and it does not help the baby find the breast or bottle.

Choice B. Grasp is not the correct answer because it is a reflex that causes the baby to close his or her fingers in a grasp when the palm of the hand is stroked, and it has nothing to do with breastfeeding.

Choice C. Tonic neck is not the correct answer because it is a reflex that causes the baby to assume a "fencing" position when the head is turned to one side, and it also has nothing to do with breastfeeding.

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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:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse assesses a postpartum woman's perineum and notices that her lochial discharge is moderate in amount and red. The nurse would record this as what type of lochia?

Correct Answer is D

Explanation

A first-time mother reports that she is experiencing difficulty breastfeeding her newborn. The neonatal reflex that the nurse would teach the mother to elicit, in order to facilitate breastfeeding is:

Correct Answer is D

Explanation

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