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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A rationale

Performing a sterile vaginal exam assesses cervical dilation and effacement, which is essential for labor progression. However, it poses an infection risk after membrane rupture and should follow fetal heart rate evaluation to ensure fetal well-being.

Choice B rationale

Establishing IV access is important for administering fluids or medications. Still, it is not immediately necessary without first assessing the fetal and maternal condition, which dictates further intervention needs.

Choice C rationale

Obtaining the fetal heart rate is the priority after membrane rupture and bloody show. It evaluates fetal oxygenation and well-being, especially with frequent contractions. Tachycardia or decelerations may indicate distress, necessitating immediate intervention.

Choice D rationale

Assessing maternal vital signs provides insight into hemodynamic status but is secondary to immediate fetal monitoring. Fetal heart rate assessment directs urgent management, especially in high-risk scenarios like ruptured membranes and bloody show. .

A. Weight gain. B. Mood changes. C. Weight loss. D. Chronic fatigue. E. Osteoporosis.

Correct Answer is ["A","B","E"]

Explanation

Choice A rationale

Weight gain is a common side effect of corticosteroids due to fluid retention and increased fat deposition. Corticosteroids stimulate appetite and alter fat metabolism, leading to central obesity and moon face, which are classic findings.

Choice B rationale

Mood changes, including irritability, depression, or euphoria, are linked to corticosteroid therapy as these medications affect the central nervous system. Neuropsychiatric symptoms can vary widely and may impact the adolescent’s quality of life and social interactions.

Choice C rationale

Weight loss is not a typical side effect of corticosteroids. These medications are more associated with increased appetite and fat redistribution, leading to weight gain rather than weight loss, making this an incorrect choice.

Choice D rationale

Chronic fatigue is not directly attributed to corticosteroids. While muscle weakness can occur due to protein catabolism, it is not synonymous with fatigue. Corticosteroids often cause insomnia, which could indirectly lead to tiredness, but this is not a primary effect.

Choice E rationale

Osteoporosis is a long-term side effect of corticosteroids due to their impact on calcium metabolism and bone resorption. These medications decrease calcium absorption, increase calcium excretion, and suppress osteoblast activity, leading to reduced bone density.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

When caring for a 13-year-old with muscular dystrophy receiving corticosteroids to slow disease progression, which of the following medication side effects would you assess for?

Correct Answer is ["A","B","E"]

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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?