A nurse is assessing the fundus of a postpartum client one day after delivery and notes that the fundus is soft and spongy.
Which is the first nursing intervention to perform?
Massage the fundus until it firms.
Notify the healthcare provider.
Document the fundal height and consistency.
Administer Oxytocin V as per MD orders.
The Correct Answer is A
Choice A rationale
Massaging the fundus is the first-line intervention when the fundus is soft and spongy, indicating uterine atony. Massage stimulates uterine contractions, reducing postpartum bleeding and restoring uterine tone, which is crucial to prevent hemorrhage.
Choice B rationale
Notifying the healthcare provider is necessary if initial interventions fail to address uterine atony. However, immediate action such as massaging the fundus should be taken first to minimize bleeding risks and stabilize the client.
Choice C rationale
Documenting fundal height and consistency is important but not an immediate intervention. Recording observations without addressing the atony fails to prevent potential complications like postpartum hemorrhage, which requires prompt and active management.
Choice D rationale
Administering Oxytocin as per MD orders aids uterine contraction but is not the first intervention. Massaging the fundus provides immediate mechanical stimulation to contract the uterus, a vital step before pharmacological measures are considered.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Performing a sharp hand clap near the infant activates the Moro reflex, a startle response present at birth that integrates by around six months of age. The reflex involves symmetric extension and abduction of the arms followed by flexion, demonstrating proper neurological function.
Choice B rationale
Placing a finger at the base of the newborn's toes elicits the plantar grasp reflex, not the Moro reflex. This reflex involves flexion of the toes when pressure is applied to the sole and is unrelated to startling the infant.
Choice C rationale
Holding the newborn vertically allowing one foot to touch the table surface elicits the stepping reflex, not the Moro reflex. This reflex involves simulated walking movements and is unrelated to assessing startle responses.
Choice D rationale
Turning the newborn's head quickly to one side elicits the tonic neck reflex (fencing reflex) rather than the Moro reflex. This reflex involves extension of the limbs on the side the head is turned and flexion on the opposite side. .
Correct Answer is B
Explanation
Choice A rationale
Increasing fundal massage frequency is not necessary when the fundus is already firm and midline. Fundal massage is primarily used to address uterine atony, which is absent in this scenario. The findings indicate normal post-delivery uterine tone rather than a complication.
Choice B rationale
Documenting the findings and monitoring the client is appropriate when the fundus is firm and midline. The presence of small clots and a large amount of lochia rubra can be normal within the first hour postpartum. Continued observation ensures any potential issues are identified early.
Choice C rationale
Immediate notification of the provider is unnecessary unless there are signs of abnormal bleeding, uterine atony, or other complications. Since the fundus is firm and midline, this suggests the uterine tone is adequate, and intervention is not urgently needed.
Choice D rationale
Encouraging the client to empty her bladder is not relevant here, as the fundus is located appropriately at the midline and umbilical level, indicating that bladder distention is not affecting uterine position. This action would not address the described findings.
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