A patient is in the immediate postpartum period after having delivered 9 pound. 14-ounce baby (4480 grams). iS 6. The patient is gravida 6, para 5. The nurse notices some new blood stains on the top sheets and discovers the patient lying in a pool of blood. The fundus is located above the umbilicus and is boggy. The bladder is not palpable. What would be the nurse's priority action?

Massage the fundus

Take the patient's blood pressure

Start an IV

Have the patient empty her bladder

Answer and Explanation

The Correct Answer is A

A) Massage the fundus:
The first priority in this situation is to massage the fundus to help control potential postpartum hemorrhage caused by uterine atony. A boggy fundus (soft and not firm) suggests that the uterus is not contracting effectively, which can lead to excessive bleeding. Massaging the fundus stimulates uterine contractions, which can help reduce bleeding by compressing the blood vessels that were supplying the placenta. The nurse should begin with this intervention immediately to address the most likely cause of the bleeding.

B) Take the patient's blood pressure:
While vital signs such as blood pressure are important for assessing shock or ongoing hemorrhage, massaging the fundus takes priority in this scenario to directly address the cause of the bleeding. Taking the blood pressure is not the most immediate intervention for this specific situation because the primary issue here is uterine atony, not hemodynamic instability (although it will need to be assessed shortly thereafter).

C) Start an IV:
Starting an IV may be important if there is significant blood loss, but it is not the first priority in this scenario. The nurse should first focus on stabilizing the uterus by massaging the fundus. IV access will become more critical if the bleeding is not controlled after the fundus is massaged and other interventions are required.

D) Have the patient empty her bladder:
While a full bladder can sometimes displace the uterus and cause it to be less effective at contracting, this is a secondary concern. The first priority is to address the uterine atony by massaging the fundus. Once the fundus is firm and bleeding is under control, the nurse can then consider having the patient empty her bladder to ensure it isn't interfering with the uterus' ability to contract.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is E

Explanation

A) Bulb syringe in crib:
While a bulb syringe can be useful for clearing the infant’s airway in case of respiratory distress, keeping it in the crib is not an optimal safety practice. The syringe should be readily available but not within reach of the infant, as it could be a choking hazard if mishandled. Ideally, it should be stored in an easily accessible area but not within the crib.

B) Secure hugs tag on and alarms activated:
Ensuring that the infant has a security tag (often referred to as a "Hugs" tag) that is properly placed and that alarms are activated is an important safety measure to prevent infant abductions. Hospitals typically use electronic security systems that alert staff if the infant is removed from the designated area without proper authorization. This intervention is essential for maintaining safety in the hospital setting.

C) ID bands match with mom's ID bands:
It is critical that the infant's ID band matches the mother's ID band. This helps prevent any mix-up or baby swap and ensures that the infant is properly identified at all times. Regular checks should be made to verify that the bands match and remain secure throughout the hospital stay.

D) Infant on their back to sleep:
Placing the infant on their back to sleep is a key guideline for reducing the risk of Sudden Infant Death Syndrome (SIDS). This position has been proven to be the safest for infants and is a crucial practice for their well-being. Educating parents and caregivers about safe sleep practices is vital for infant safety.

E) All of the above:
All of these practices are part of a comprehensive safety plan for the infant. Ensuring that the infant is safely secured with proper identification, preventing any risk of abduction, promoting safe sleep practices, and ensuring that airway equipment is available are all essential measures in maintaining the safety of the newborn. Therefore, the correct response is "All of the above."

A. Developing Prolactin Receptor Sites B. Decreasing Oxytocin C. Decreasing Estrogen D. Increasing Estrogen

Correct Answer is A

Explanation

A) Developing Prolactin Receptor Sites:
The first 1-5 days postpartum are critical for breastfeeding success because this period is when the prolactin receptor sites in the mother's breast tissue are being established. Prolactin is the hormone responsible for milk production, and the more prolactin receptor sites developed, the more efficiently the body can respond to the baby’s sucking and produce milk. This is the foundation for a successful breastfeeding relationship, as proper stimulation in these early days encourages the long-term supply of milk.

B) Decreasing Oxytocin:
Oxytocin is the hormone responsible for milk ejection (let-down) and is crucial for breastfeeding. In the early postpartum period, oxytocin levels are actually high and remain important for milk release, not decreasing. A decrease in oxytocin would impair milk ejection, which could affect breastfeeding success.

C) Decreasing Estrogen:
Estrogen levels drop significantly after delivery, which is part of the process that allows milk production to take precedence over pregnancy-related hormones. However, the drop in estrogen is more of a secondary event in breastfeeding success compared to the development of prolactin receptor sites. Estrogen primarily impacts lactation later, such as with the onset of menstruation.

D) Increasing Estrogen:
Estrogen levels rise during pregnancy, but they begin to decrease rapidly after birth. Higher levels of estrogen inhibit lactation during pregnancy, which is why the postpartum drop in estrogen is important for milk production to commence. However, an increase in estrogen would actually hinder the initiation of lactation and is not a factor in the success of breastfeeding in the early postpartum period.

View Question and Answer

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

You know that infant safety is important so which of the following should be in place to maintain infant safety:

Correct Answer is E

Explanation

Day 1 - 5 postpartum is significant in breastfeeding success due to what process?

Correct Answer is A

Explanation

A nurse is assessing a newborn at 2 hours of life. Which of the following findings should the nurse report to the neonatologist?

The nurse is teaching a newborn care class to parents who are about to give birth to their first babies. Which statement indicates that teaching was effective?

A nurse is giving discharge instructions to a new mother. What is the most important instruction to address the prevention of postpartum infection?

A new mother asks the nurse about the white substance" covering her infant. The nurse explains that the purpose of vernix caseosa is to:

Which nursing action is most appropriate to correct a boggy uterus that is displaced above and to the right of the umbilicus?

You are in the postpartum unit where a Day two G1P1 Mother is working hard at breastfeeding her baby. She is concerned that the baby is fussy between feedings. The advice you would give her is:

Rh, immune globulin will be ordered after birth if which situation occurs?

Thirty minutes after childbirth, a client's fundus is firm, shifted to the right of the midline above the umbilicus. Based on this finding, how will the nurse intervene?