Nokea
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.
You may also like to solve these questions
What assessment finding suggests a possible infection?
- A. painful fundal massage
- B. breast-feeding every 2–3 hours
- C. pulse 72
- D. WBCs 10,000
Correct Answer: D
Rationale: Painful fundal massage can indicate a potential infection.
The nurse has provided teaching to a post-op cesarean client who is being discharged on Colace (docusate sodium) 100 mg po tid. Which of the following would indicate that the teaching was successful?
- A. The woman swallows the tablets whole.
- B. The woman takes the pills between meals.
- C. The woman calls the doctor if she develops a headache.
- D. The woman understands that her urine may turn orange.
Correct Answer: D
Rationale: Colace (docusate sodium) is a stool softener that can turn the urine orange. This is a common side effect and should be discussed with the patient during teaching to avoid unnecessary concern.
A breastfeeding mother states that she has sore nipples. In response to the complaint, the nurse assists with 'latch on ' and recommends that the mother do which of the following?
- A. Use a nipple shield at each breastfeeding.
- B. Cleanse the nipples with soap 3 times a day.
- C. Rotate the baby 's positions at each feed.
- D. Bottle feed for 2 days then resume breastfeeding.
Correct Answer: C
Rationale: Rotating positions during breastfeeding helps to prevent sore spots and promotes proper latch.
What is a symptom of engorgement?
- A. protuberant nipples
- B. shiny, hard breast
- C. insufficient milk production
- D. soft, lumpy breast
Correct Answer: B
Rationale: Shiny, hard breasts are characteristic of engorgement.
The nurse is providing care for a patient who is 8 hours postpartum after a vaginal delivery. The patient reports severe perineal pain unaffected by pain medication. The nurse notices a 4 cm area of discoloration on the labia that is tender to the touch. Which action does the nurse take?
- A. Continue to apply ice to the area for 24 hours.
- B. Monitor vital signs and report any abnormal readings.
- C. Contact the primary care provider for further evaluation.
- D. Relieve pressure by placing patient in a side-lying position.
Correct Answer: C
Rationale: The correct answer is C: Contact the primary care provider for further evaluation. The patient's symptoms of severe perineal pain, discoloration on the labia, and tenderness indicate a potential complication such as hematoma or infection. Contacting the primary care provider is essential for prompt assessment and appropriate intervention to prevent further complications. Continuing to apply ice (A) may not address the underlying issue and could potentially worsen the condition. Monitoring vital signs (B) is important but may not provide direct insight into the specific problem. Relieving pressure by placing the patient in a side-lying position (D) is not the priority in this situation and may not address the underlying cause of the symptoms.