A nurse is assessing the fundus of a postpartum patient one day after delivery and notes that the fundus is soft and spongy. Which is the first nursing intervention to preform?
Administer Oxytocin IV per MD orders
Notify the healthcare provider
Document the fundal height and consistency
Massage the fundus until it firms
The Correct Answer is D
A. Administer Oxytocin IV per MD orders. This may be done after attempting fundal massage to help firm the uterus, but massage is the first step.
B. Notify the healthcare provider. This would be done if the fundus does not respond to massage or if excessive bleeding continues, but not before attempting to firm the fundus.
C. Document the fundal height and consistency. Documentation is important but should occur after addressing the immediate issue of a soft fundus to prevent hemorrhage.
D. Massage the fundus until it firms. The immediate action should be to massage the uterus to promote contraction and reduce bleeding. A soft, spongy uterus indicates uterine atony, which can lead to hemorrhage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Limit alcohol and caffeine intake. This is important for bone health and overall well-being during menopause, especially since alcohol and caffeine can affect bone density.
B. Decreasing the intake of dairy products. While calcium intake is important, decreasing dairy intake is not a recommended strategy during menopause unless there are specific dietary restrictions or intolerances.
C. Performing regular weight-bearing exercises. This is important for maintaining bone density but may not be the most important measure compared to limiting alcohol and caffeine intake.
D. Taking vitamin E and B complex vitamin supplements. While vitamins are important, they are not as critical as lifestyle measures like limiting alcohol and caffeine.
Correct Answer is A
Explanation
A. Pain. Pain is the hallmark symptom of a sickle cell crisis due to the vaso-occlusion of sickled red blood cells blocking blood flow and causing ischemia in various tissues and organs.
B. High fever. While fever can occur if there is an associated infection, it is not a primary feature of sickle cell crisis.
C. Bradycardia. Sickle cell crisis can cause tachycardia due to pain and stress, but not bradycardia.
D. Constipation. This is not a typical symptom associated with a sickle cell crisis.
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