Nokea
The nurse assesses the fundus and finds it to be boggy, elevated >2 fingerbreadths above the umbilicus, and deviated to one side. What is the common cause of this finding?
- A. uterine rupture
- B. full bladder
- C. perineal laceration
- D. hematoma
Correct Answer: B
Rationale: A full bladder can displace the uterus and prevent it from contracting properly leading to a boggy fundus.
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The nurse is performing an assessment of the uterus 30 minutes after a normal delivery and finds the fundus to be soft and boggy. IV Pitocin is infusing at 150 mL/hr. What is the priority nursing intervention?
- A. Increase the Pitocin, assess the fundus in 15 minutes, and update the licensed provider.
- B. Perform external massage of the uterus until it is firm, assess for additional bleeding on the pad, and update the licensed provider.
- C. Notify the provider of the increase in blood loss.
- D. Assist the patient to the bathroom and reassess the fundus after the patient voids.
Correct Answer: B
Rationale: Performing external massage of the uterus and updating the provider is essential in managing a soft and boggy fundus.
What postpartum infection can be transferred between the breast-feeding person and newborn if both are not treated appropriately?
- A. wound infection
- B. urinary tract infection
- C. thrush
- D. mastitis
Correct Answer: C
Rationale: Thrush is a fungal infection that can be transferred between the breastfeeding person and the newborn requiring appropriate treatment for both.
Which condition is considered a medical emergency that requires immediate treatment?
- A. Inversion of the uterus
- B. Hypotonic uterus
- C. ITP
- D. Uterine atony
Correct Answer: A
Rationale: Inversion of the uterus is considered a medical emergency that requires immediate treatment. It occurs when the uterus turns inside out and protrudes through the cervix, which can lead to severe hemorrhage and shock. Prompt intervention is crucial to restore the uterus to its normal position, control bleeding, and prevent further complications such as infection or tissue necrosis. Failure to address uterine inversion promptly can result in life-threatening consequences for the mother. In contrast, hypotonic uterus, ITP (Idiopathic Thrombocytopenic Purpura), and uterine atony, while serious conditions, do not typically constitute immediate emergencies that necessitate urgent intervention on the same time-critical scale as uterine inversion.
The nurse notices the person with a PPH looks pale and their capillary refill is >3 seconds. What intervention can the nurse initiate?
- A. Wrap the person in a warm blanket.
- B. Put a pulse oximeter on the patient’s finger.
- C. Sit the person up at 90 degrees.
- D. Start an IV bolus.
Correct Answer: D
Rationale: A pale appearance with delayed capillary refill is indicative of shock and may require rapid intervention.
The nurse palpates a distended bladder on a woman who delivered vaginally 2 hours earlier. The woman refuses to go to the bathroom, 'I really don 't need to go. ' Which of the following responses by the nurse is appropriate?
- A. Okay. I must be palpating your uterus.
- B. I understand but I still would like you to try to urinate.
- C. You still must be numb from the local anesthesia.
- D. That is a problem. I will have to catheterize you.
Correct Answer: B
Rationale: A distended bladder can lead to complications such as uterine atony. The nurse should encourage the woman to attempt urination, but if she refuses, further action may be necessary.