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

Alcohol swabs are not recommended for cleaning the circumcision site as they may irritate the delicate tissue and delay healing. Proper care involves gentle cleansing with water and avoiding substances that can cause discomfort or tissue damage.

Choice B rationale

While monitoring for bleeding is essential, small spots of blood on the diaper may be normal. Excessive bleeding, however, is a cause for concern and should prompt immediate medical consultation, emphasizing the need to differentiate normal healing signs from complications.

Choice C rationale

A loose diaper reduces pressure on the circumcision site and prevents friction, which could cause pain or disrupt the healing process. This practice ensures the Plastibell stays in position until it detaches naturally, minimizing discomfort and promoting tissue recovery.

Choice D rationale

The Plastibell typically falls off within 5 to 8 days, not within 24 hours. Misunderstanding this timeframe can cause undue anxiety for parents or lead to premature removal attempts, which may complicate the healing process or cause injury to the site.

A. Playing on the backyard swings and running around outside are exercises our child will really enjoy. B. Three to four times a day we will perform chest therapy and postural drainage on our child. C. A high-protein, high-calorie diet may need to be supplemented with a high-calorie formula. D. Pancreatic enzymes will not be necessary if our child has a good appetite and regular bowel movements.

Correct Answer is D

Explanation

Choice A rationale

Exercise is encouraged for cystic fibrosis patients as it improves respiratory function and overall physical health. Outdoor activities like swinging and running benefit the child by promoting lung clearance through increased breathing depth, which supports disease management and physical development.

Choice B rationale

Chest therapy and postural drainage improve mucus clearance and lung function in cystic fibrosis patients. Performing these interventions regularly ensures respiratory health by reducing mucus accumulation and preventing infections, promoting the child’s well-being.

Choice C rationale

High-protein, high-calorie diets are essential for cystic fibrosis patients due to increased metabolic demands. Supplementing the diet with high-calorie formula supports weight gain and compensates for malabsorption. These interventions are pivotal for growth and energy maintenance.

Choice D rationale

Pancreatic enzymes are crucial for digestion and nutrient absorption in cystic fibrosis patients, as pancreatic insufficiency leads to malabsorption. Even with good appetite and bowel movements, skipping enzyme supplementation results in nutrient deficiencies, growth delays, and gastrointestinal issues.

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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

A nurse on a postpartum unit is giving discharge instructions to a client whose newborn had a circumcision with a Plastibell technique.Which of the following client statements indicates an understanding of circumcision care?

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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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?