Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is assessing the fundus of a postpartum patient one day after delivery and notes that the fundus is soft and spongy. Which is the first nursing intervention to preform?
A. Administer Oxytocin IV per MD orders
Administer Oxytocin IV per MD orders. This may be done after attempting fundal massage to help firm the uterus, but massage is the first step.
B. Notify the healthcare provider
Notify the healthcare provider. This would be done if the fundus does not respond to massage or if excessive bleeding continues, but not before attempting to firm the fundus.
C. Document the fundal height and consistency
Document the fundal height and consistency. Documentation is important but should occur after addressing the immediate issue of a soft fundus to prevent hemorrhage.
D. Massage the fundus until it firms
Massage the fundus until it firms. The immediate action should be to massage the uterus to promote contraction and reduce bleeding. A soft, spongy uterus indicates uterine atony, which can lead to hemorrhage.
This question is an excerpt from Nurse Dive's nursing test bank - Ati Nur 209 Reproductive Health Proctored Exam. Take the full exam now
Full Explanation
A. Administer Oxytocin IV per MD orders. This may be done after attempting fundal massage to help firm the uterus, but massage is the first step.
B. Notify the healthcare provider. This would be done if the fundus does not respond to massage or if excessive bleeding continues, but not before attempting to firm the fundus.
C. Document the fundal height and consistency. Documentation is important but should occur after addressing the immediate issue of a soft fundus to prevent hemorrhage.
D. Massage the fundus until it firms. The immediate action should be to massage the uterus to promote contraction and reduce bleeding. A soft, spongy uterus indicates uterine atony, which can lead to hemorrhage.
Similar Questions
What is the priority nursing intervention to perform on an infant immediately following repair of a myelomeningocele?
A. Assess motor function in lower extremities
Assess motor function in lower extremities: While important for overall neurological assessment, immediate post-repair monitoring of motor function is secondary to monitoring for signs of hydrocephalus (head circumference).
B. Maintain skin integrity
Maintain skin integrity: Essential for preventing infection but does not address the immediate post-surgical complication of hydrocephalus.
C. Monitor intake and output
Monitor intake and output: Important for general post-operative care but does not address the immediate concern of monitoring for hydrocephalus.
D. Monitor head circumference
Monitor head circumference: Following repair of a myelomeningocele, infants are at risk for developing hydrocephalus due to abnormal cerebrospinal fluid dynamics. Monitoring head circumference helps detect early signs of increased intracranial pressure, a common complication post-surgery.
Full Explanation
A. Assess motor function in lower extremities: While important for overall neurological assessment, immediate post-repair monitoring of motor function is secondary to monitoring for signs of hydrocephalus (head circumference).
B. Maintain skin integrity: Essential for preventing infection but does not address the immediate post-surgical complication of hydrocephalus.
C. Monitor intake and output: Important for general post-operative care but does not address the immediate concern of monitoring for hydrocephalus.
D. Monitor head circumference: Following repair of a myelomeningocele, infants are at risk for developing hydrocephalus due to abnormal cerebrospinal fluid dynamics. Monitoring head circumference helps detect early signs of increased intracranial pressure, a common complication post-surgery.
A nurse in an acute pediatric unit is assessing a 5-year-old child following an asthma event. The child's caregiver expects the child to use an inhaler without supervision. The nurse can apply which of the following interventions as protective factors for the child? (Select All that Apply.)
A. Provide the caregiver with resources in the community for support
Provide the caregiver with resources in the community for support: Ensures the caregiver has access to additional help and knowledge about asthma management.
B. Provide the child with a pamphlet on how to use an inhaler
Provide the child with a pamphlet on how to use an inhaler: While education for the child is important, at 5 years old, the ability to manage an inhaler independently may not be developmentally appropriate.
C. Refer the caregiver to the asthma educator
Refer the caregiver to the asthma educator: Specialized instruction can enhance the caregiver's understanding of asthma management.
D. Ask the caregiver, "what worries you about your child?"
Ask the caregiver, "what worries you about your child?": Understanding concerns helps tailor education and support to address specific needs.
E. Teach the child how to use the inhaler
Teach the child how to use the inhaler: Similar to B, teaching the child directly to use the inhaler without supervision may not be feasible at this age.
F. Provide information on child development to the caregiver on when a child should be able to use an inhaler without supervision
Provide information on child development: Educates the caregiver about realistic expectations regarding the child's ability to manage asthma independently.
Full Explanation
A. Provide the caregiver with resources in the community for support: Ensures the caregiver has access to additional help and knowledge about asthma management.
B. Provide the child with a pamphlet on how to use an inhaler: While education for the child is important, at 5 years old, the ability to manage an inhaler independently may not be developmentally appropriate.
C. Refer the caregiver to the asthma educator: Specialized instruction can enhance the caregiver's understanding of asthma management.
D. Ask the caregiver, "what worries you about your child?": Understanding concerns helps tailor education and support to address specific needs.
E. Teach the child how to use the inhaler: Similar to B, teaching the child directly to use the inhaler without supervision may not be feasible at this age.
F. Provide information on child development: Educates the caregiver about realistic expectations regarding the child's ability to manage asthma independently.
When performing an initial assessment on a full-term infant whose parents are Asian, the nurse notes a blue-gray discoloration across the sacrum of the newborn. What is the most appropriate action for the nurse to take?
A. Review clotting studies lab report
Review clotting studies lab report: Not relevant to the assessment finding of a blue-gray discoloration.
B. Notify the healthcare provider
Notify the healthcare provider: Unnecessary unless there are other concerning clinical findings.
C. Document the findings in the electronic health record
Document the findings in the electronic health record: A blue-gray discoloration across the sacrum is likely a Mongolian spot, a benign condition more commonly seen in infants of Asian, African, Native American, and Hispanic descent. Documenting this finding in the electronic health record ensures accurate and comprehensive medical documentation without unnecessary interventions.
D. Report parents to Child Protective Services
Report parents to Child Protective Services: Inappropriate as this finding is a benign condition common among certain ethnic groups and not indicative of abuse.
Full Explanation
A. Review clotting studies lab report: Not relevant to the assessment finding of a blue-gray discoloration.
B. Notify the healthcare provider: Unnecessary unless there are other concerning clinical findings.
C. Document the findings in the electronic health record: A blue-gray discoloration across the sacrum is likely a Mongolian spot, a benign condition more commonly seen in infants of Asian, African, Native American, and Hispanic descent. Documenting this finding in the electronic health record ensures accurate and comprehensive medical documentation without unnecessary interventions.
D. Report parents to Child Protective Services: Inappropriate as this finding is a benign condition common among certain ethnic groups and not indicative of abuse.