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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 B

Explanation

Choice A reason: Administering immune globulin as soon as possible after delivery is a correct step but does not include the critical combination of both immune globulin and the hepatitis B vaccine, which provides optimal protection for the newborn against hepatitis B.

Choice B reason: The combination of hepatitis B immune globulin and hepatitis B vaccine given within 12 hours of birth is the most effective intervention for preventing hepatitis B transmission from the parent to the infant. This approach ensures immediate passive immunity through the immune globulin and active immunity through the vaccine, significantly reducing the risk of the newborn developing hepatitis B.

Choice C reason: Administering hepatitis B immune globulin within 20 hours after birth delays the initiation of protective measures compared to the 12-hour window. It is essential to provide both immune globulin and the vaccine as early as possible to maximize the protective effect against hepatitis B.

Choice D reason: Administering the hepatitis B vaccine 24 hours after birth is too late for immediate protection against the virus. The combination of immune globulin and vaccine should be provided within the first 12 hours to ensure the highest level of protection for the newborn. Delaying the vaccination could increase the risk of hepatitis B transmission and infection.

A. Have the caregivers in the room with the patient. B. Provide written reading materials. C. Educate the patient to avoid sexual activity. D. Assess the patient alone.

Correct Answer is D

Explanation

Choice A reason: Having the caregivers in the room with the patient may not provide a confidential and comfortable environment for the 16-year-old. Adolescents may feel embarrassed or reluctant to discuss sensitive issues related to sexually transmitted infections (STIs) in front of their caregivers. This approach does not fully support patient-cantered care, which focuses on respecting the patient’s privacy and promoting open communication.

Choice B reason: Providing written reading materials is an important aspect of education, but it may not be sufficient on its own to ensure that the patient fully understands the information. Reading materials should be supplemented with personalized discussion to address specific concerns and questions the patient may have. Therefore, while helpful, this intervention alone does not represent the most patient-cantered approach.

Choice C reason: Educating the patient to avoid sexual activity is a limited approach that does not consider the complexities of an adolescent's experiences and needs. A more patient-cantered approach would involve discussing safe sexual practices, STI prevention methods, and empowering the patient with comprehensive information to make informed decisions about their sexual health, rather than simply advising abstinence.

Choice D reason: Assessing the patient alone provides a private and supportive environment where the 16-year-old can feel more comfortable discussing sensitive topics. This approach respects the patient’s autonomy, ensures confidentiality, and allows for more open and honest communication. It demonstrates a commitment to patient-cantered care by addressing the individual needs and concerns of the patient.

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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 caring for a 37-weeks gestation infant born to a parent with hepatitis B. Which intervention will the nurse include in the plan of care?

Correct Answer is B

Explanation

The nurse is providing sexually transmitted infection education to a 16-year-old. What nursing intervention demonstrates patient-cantered care?

Correct Answer is D

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.