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

Answer and Explanation

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.

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Correct Answer is ["A","C","D","F"]

Explanation

A. Provide the caregiver with resources in the community for support: Ensures the caregiver has access to additional help and knowledge about asthma management.
B. Provide the child with a pamphlet on how to use an inhaler: While education for the child is important, at 5 years old, the ability to manage an inhaler independently may not be developmentally appropriate.
C. Refer the caregiver to the asthma educator: Specialized instruction can enhance the caregiver's understanding of asthma management.
D. Ask the caregiver, "what worries you about your child?": Understanding concerns helps tailor education and support to address specific needs.
E. Teach the child how to use the inhaler: Similar to B, teaching the child directly to use the inhaler without supervision may not be feasible at this age.
F. Provide information on child development: Educates the caregiver about realistic expectations regarding the child's ability to manage asthma independently.

A. Gender can be determined B. Surfactant production C. Sucking occurs D. Fetus has a heartbeat E. Fetal respiratory movements begin F. Increase in body fat

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"C"},"C":{"answers":"C"},"D":{"answers":"A"},"E":{"answers":"C"},"F":{"answers":"C"}}

Explanation

1st Trimester (Conception-13 weeks)

Fetus has a heartbeat: The fetal heartbeat can typically be detected around 6 weeks gestation using ultrasound, marking the beginning of cardiac development in the first trimester.

2nd Trimester (14-26 weeks)

Gender can be determined: Gender determination through ultrasound is generally possible around the 18-20 week mark in the second trimester when fetal genitalia are more distinguishable.

3rd Trimester (27-40 weeks)

Surfactant production: Surfactant production by the fetal lungs begins in the third trimester, usually around 24-28 weeks, but continues to increase throughout the remainder of pregnancy.
Sucking occurs: Fetal sucking movements start to develop around the 28th week and become more coordinated as the third trimester progresses.
Fetal respiratory movements begin: Fetal respiratory movements, where the fetus practices breathing by moving the diaphragm, begin in the third trimester to prepare for life outside the womb.
Increase in body fat: The fetus begins to accumulate more body fat in the third trimester, which helps with thermoregulation and provides energy reserves for birth and early postnatal life.

Finding	1st Trimester Conception-13 weeks	2nd Trimester 14-26 weeks	3rd Trimester 27-40 weeks

Gender can be determined	☐	☒	☐
Surfactant production	☐	☐	☒
Sucking occurs	☐	☐	☒
Fetus has a heartbeat	☒	☐
Fetal respiratory movements begin	☐	☐	☒
Increase in body fat	☐	☐	☐

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in an acute pediatric unit is assessing a 5-year-old child following an asthma event. The child's caregiver expects the child to use an inhaler without supervision. The nurse can apply which of the following interventions as protective factors for the child? (Select All that Apply.)

Correct Answer is ["A","C","D","F"]

Explanation

Identify the trimester when each fetal development finding occurs. Note: Each category must have at least 1 response option selected.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"C"},"C":{"answers":"C"},"D":{"answers":"A"},"E":{"answers":"C"},"F":{"answers":"C"}}

Explanation

A nurse manager is providing staff education about working with clients who have a history of anger and aggression. Which of the following Information should the nurse manager include in the teaching? (Select all that apply.)

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A nurse is caring for a client who is 1 hr postpartum and observes a large amount of lochia rubra and several small clots on the client's perineal pad. The fundus is midline and firm at the umbilicus. Which of the following actions should the nurse take?

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?

You are the nurse caring for an infant with an order to receive Amoxicillin (Amoxil) orally every 6 hours. The safe medication dose is 50mg/kg/day in divided doses. The infant weighs 6 kgs. How much medication will you administer to the infant each dose?