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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 D

Explanation

Choice A reason: While some children with cerebral palsy may have intellectual delays, it is not accurate to generalize this condition as affecting all children with cerebral palsy. The extent of intellectual involvement can vary widely. Therefore, stating this as a definite teaching point may not be appropriate for every child.

Choice B reason: Cerebral palsy is not typically considered a genetic disorder. It is most commonly caused by damage to the developing brain either during pregnancy, childbirth, or shortly after birth. Factors that contribute to cerebral palsy can include infections, lack of oxygen, and traumatic injuries, but it is not primarily a genetic condition.

Choice C reason: While cerebral palsy can impact a child's overall health and development, stating that it will shorten the child's lifespan is not necessarily true. Many individuals with cerebral palsy live into adulthood, and lifespan can vary widely depending on the severity of the condition and the presence of associated health issues.

Choice D reason: Cerebral palsy is accurately described as a non-progressive disorder. This means that while the symptoms of cerebral palsy can change over time (due to growth, development, and other factors), the underlying brain injury does not worsen. Understanding that cerebral palsy is non-progressive can help parents focus on managing symptoms and improving their child's quality of life.

A. Seek medical attention if the newborn has a fever. B. Watch out for yellowing of the skin or eyes. C. Adhere to the recommended vaccine schedule. D. Administer factor VIII replacement as indicated. E. Provide oral penicillin V potassium to prevent infection.

Correct Answer is ["A","B","C","E"]

Explanation

Choice A reason: Seeking medical attention if the newborn has a fever is crucial for children with sickle cell anaemia. Fever can be an early sign of infection, and children with sickle cell anaemia are at a higher risk for infections. Prompt medical evaluation and treatment are necessary to prevent severe complications.

Choice B reason: Watching out for yellowing of the skin or eyes (jaundice) is important because it can indicate homolysis, a common issue in sickle cell anaemia where red blood cells break down rapidly. Identifying jaundice early allows for timely medical intervention to address underlying causes and prevent further complications.

Choice C reason: Adhering to the recommended vaccine schedule is essential for protecting children with sickle cell anaemia from preventable infections. Their immune systems are often compromised, making them more susceptible to infections that vaccines can help prevent.

Choice D reason: Administering factor VIII replacement is not relevant to sickle cell anaemia. Factor VIII replacement is a treatment for haemophilia, a different blood disorder. This intervention is not applicable in the context of sickle cell anaemia education.

Choice E reason: Providing oral penicillin V potassium to prevent infection is a standard recommendation for children with sickle cell anaemia. Daily prophylactic penicillin helps reduce the risk of serious infections, particularly from Streptococcus pneumoniae, which can be life-threatening in these patients.

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is teaching parents about their child newly diagnosed with cerebral palsy. What will the nurse include in the teaching?

Correct Answer is D

Explanation

The nurse is teaching parents of a newborn recently diagnosed with sickle cell anaemia. Which interventions will the nurse include in the education? Select all that apply.

Correct Answer is ["A","B","C","E"]

Explanation

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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.