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 B
Explanation
Choice A rationale
A positive rubella serum antibody titer indicates immunity to rubella infection, which is protective during pregnancy. It is not an abnormal finding and does not require immediate reporting. Rubella immunity is important to prevent congenital rubella syndrome in the fetus, a severe condition causing defects such as deafness or cardiac anomalies.
Choice B rationale
Blood pressure of 144/94 mmHg is elevated and indicates gestational hypertension, which could progress to preeclampsia if not managed. Preeclampsia can lead to complications such as eclampsia, placental abruption, or maternal and fetal mortality. Normal blood pressure during pregnancy is less than 140/90 mmHg, making this finding critical to report.
Choice C rationale
Copious leukorrhea is a common physiological change in pregnancy due to increased estrogen levels and vascularity. It is usually benign and protective, preventing infections by maintaining a mildly acidic environment in the vagina. This finding does not warrant immediate concern unless associated with infection symptoms.
Choice D rationale
An O-negative blood type requires administration of Rh immunoglobulin to prevent Rh isoimmunization, but this is routinely managed in pregnancy. It is not an urgent issue unless there are concerns about fetomaternal hemorrhage or alloimmunization, which could harm an Rh-positive fetus.
Correct Answer is ["A","B","C","D"]
Explanation
Choice A rationale
Difficulty feeding in infants can result from fatigue caused by inadequate oxygen delivery to tissues due to heart failure. Feeding is a demanding activity that requires energy and coordination, making it an early symptom of cardiac compromise in pediatric patients.
Choice B rationale
Wheezes or rales are caused by pulmonary congestion or edema, which occur in heart failure due to increased pulmonary venous pressure. This congestion results in fluid accumulation in the alveoli, leading to abnormal breath sounds. These findings require prompt evaluation.
Choice C rationale
Edema in the feet and legs results from systemic venous congestion caused by right-sided heart failure. Increased hydrostatic pressure in peripheral veins leads to fluid leakage into interstitial spaces, causing swelling, especially in dependent areas.
Choice D rationale
Tachypnea occurs as a compensatory mechanism in heart failure. Poor cardiac output reduces oxygen delivery, triggering the respiratory center to increase the breathing rate to improve oxygen uptake and delivery. It is an early sign of cardiopulmonary compromise in children.
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