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"]

Explanation

A. Fetal breathing. The biophysical profile assesses fetal breathing movements as one of the components indicating fetal well-being.
B. Fetal neck translucency. This is not part of the biophysical profile; it is typically assessed during first-trimester screening for chromosomal abnormalities.
C. Fetal motion. Fetal movements are another component of the biophysical profile, reflecting the fetal central nervous system integrity and oxygenation.
D. Amniotic fluid volume. The assessment of amniotic fluid volume is crucial in determining fetal well-being and adequate fetal renal function.
E. Fetal gender. Gender is not assessed as part of the biophysical profile; the test focuses on fetal physiological parameters related to well-being.

A. The newborn who has cyanotic hands and feet. B. The newborns whose head turns toward the cheek being stroked C. The newborn whose toes curl when the lateral heel is stroked D. The newborn who extends the arms when hearing a loud noise

Correct Answer is A

Explanation

A. The newborn who has cyanotic hands and feetCyanosis, a bluish or purplish discoloration of the skin, in the hands and feet of a newborn can indicate a breathing problem or poor circulation. This requires prompt evaluation by a healthcare provider.
B. The newborn whose head turns toward the cheek being stroked. This describes the rooting reflex, which is normal.
C. The newborn whose toes curl when the lateral heel is stroked. This describes the Babinski reflex, which is also normal for infants.
D. The newborn who extends the arms when hearing a loud noise. This describes the Moro reflex, which is normal and should not require reporting.

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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 is caring for a client having a biophysical profile. The client asks what the test is for. What should the nurse include in the response? (Select All that Apply.)

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

Explanation

Which newborn assessment finding would require the nurse to report to the health care provider?

Correct Answer is A

Explanation

Which three (3) assessment findings indicate that the breastfeeding client has achieved a proper latch?

A nurse is discharging a child who has sickle cell anemia after an acute crisis episode. Which of the following instructions should the nurse include in the teaching?

A nurse is caring for a client diagnosed with anorexia nervosa and over exercises to avoid gaining weight. Which of the following should be the appropriate action by the nurse?

Which statement made by a pregnant patient indicates teaching was effective related to an elevated alpha fetoprotein (AFP) level?

A nurse is assessing a newborn who has Trisomy 21 (Down's Syndrome). Which of the following are common characteristics? (Select All that Apply.)

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.)

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 her son's circumcision care? (Select All that Apply.)

The nurse places an infant with a tracheoesophageal fistula under a radiant warmer with the infant's head elevated at a 45-degree angle. Which statement by the mother indicates an understanding of the most important reason for this position?