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The nurse is completing a fundal assessment on a patient who had a vaginal delivery 4 hours ago.

Place in sequential order the actions the nurse will take to assess the fundus.

Place one hand on the lower segment of the uterus.

Position the patient in a supine position.

Gently massage the fundus in a circular motion.

Press at the level of the umbilicus to palpate the fundus.

Answer and Explanation

The Correct Answer is B,A,D,C

The correct order is: b, a, d, c

b) Position the patient in a supine position: The first step is to ensure the patient is in a supine position, which is lying on their back. This position provides the best access and visibility for the nurse to assess the fundus effectively. Ensuring the patient is comfortable and relaxed in this position is crucial before beginning the assessment.
a) Place one hand on the lower segment of the uterus: The next step involves placing one hand on the lower segment of the uterus. This helps to stabilize the uterus and provides support while the nurse palpates the fundus. It also prevents any excessive movement that could cause discomfort or complications.
d) Press at the level of the umbilicus to palpate the fundus: The nurse then presses at the level of the umbilicus (belly button) to palpate the fundus. The fundus is the top portion of the uterus, and assessing its position and firmness provides important information about the postpartum recovery process.
c) Gently massage the fundus in a circular motion: Finally, the nurse gently massages the fundus in a circular motion. This action helps to ensure the uterus remains firm and can help in preventing postpartum haemorrhage. If the fundus is not firm, the massage can stimulate uterine contractions to firm it up.

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Correct Answer is A

Explanation

Choice A reason: Warming the stethoscope before use prevents heat loss through conduction. Conduction is the transfer of heat from the infant's body to a cooler surface or object that comes in direct contact with them. By warming the stethoscope, the nurse ensures that the infant does not lose heat to the cold surface of the stethoscope, thereby helping to maintain the infant's body temperature.

Choice B reason: Moving the infant away from a drafty vent helps prevent heat loss through convection, not conduction. Convection is the transfer of heat through air currents, and keeping the infant away from drafts helps minimize this type of heat loss.

Choice C reason: Drying the infant with a towel prevents heat loss through evaporation. When a wet infant is dried, it helps reduce the loss of heat that occurs as moisture evaporates from the skin.

Choice D reason: Closing the doors to the isolate helps prevent heat loss through radiation. Radiation is the transfer of heat from the infant's body to cooler surrounding surfaces. By closing the doors, the nurse helps maintain a warm environment, reducing heat loss.

A. The patient who is 11 weeks pregnant and nauseous, tired, and sleepy most of the day. B. The patient who is 30 weeks pregnant complained of "blurred vision and seeing spots." C. The patient who is 40 weeks pregnant and has to urinate every 2 hours. D. The patient who is 37 weeks pregnant and has 4 to 5 contractions in an hour.

Correct Answer is B

Explanation

Choice A reason: While nausea, tiredness, and sleepiness are common during the first trimester of pregnancy, they are typically not signs of an immediate emergency. This patient does not exhibit any alarming symptoms that would require immediate hospital referral.

Choice B reason: Blurred vision and seeing spots during pregnancy can be symptoms of preeclampsia, a potentially dangerous condition characterized by high blood pressure. Preeclampsia can pose serious health risks to both the mother and the baby and requires immediate medical attention.

Choice C reason: Frequent urination is a common symptom in the later stages of pregnancy due to the pressure the growing baby exerts on the bladder. This symptom alone does not indicate an immediate need for hospital evaluation.

Choice D reason: Having 4 to 5 contractions in an hour at 37 weeks of pregnancy can be a sign of early labor. However, unless the contractions are persistent and intensifying, this may not necessitate an immediate hospital referral. The nurse would likely advise the patient to monitor the contractions and come in if they continue or become stronger.

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The nurse is completing a fundal assessment on a patient who had a vaginal delivery 4 hours ago. Place in sequential order the actions the nurse will take to assess the fundus.

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Correct Answer is A

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Correct Answer is B

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The nurse is completing a fundal assessment on a patient who had a vaginal delivery 4 hours ago.

Place in sequential order the actions the nurse will take to assess the fundus.