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
Pain is a hallmark symptom of sickle cell crisis due to vaso-occlusion, which restricts blood flow and oxygen delivery to tissues. It results from ischemia in affected areas, triggering severe discomfort that requires prompt management with analgesics and interventions to improve circulation.
Choice B rationale
Constipation is not typically associated with sickle cell crisis. While dehydration might contribute to gastrointestinal changes, the primary symptoms revolve around pain and vaso-occlusive events impacting blood flow and oxygen delivery.
Choice C rationale
High fever can occur due to infections secondary to spleen dysfunction in sickle cell patients, but it is not a direct symptom of crisis itself. Fever requires evaluation to rule out underlying causes, as infections pose serious risks for these individuals.
Choice D rationale
Bradycardia is atypical in sickle cell crisis. Instead, tachycardia may occur due to compensatory mechanisms for ischemia and hypoxia. Bradycardia is unrelated to the vaso-occlusive events characteristic of sickle cell crises. .
Correct Answer is ["75"]
Explanation
Step 1 is (50 mg × 6 kg) ÷ 24 hours. The total daily dose calculates to 300 mg/day.
Step 2 is 300 mg ÷ 4 doses/day. Each dose calculates to 75 mg of Amoxicillin.
Final calculated dose per administration is 75 mg.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.