If a woman's fundus is soft 30 minutes after birth, the nurse's first response should be to:
a. massage the fundus.
b. take the blood pressure.
c. notify the physician or nurse-midwife.
d. place the woman in Trendelenburg position.
ANS: A
The nurse's first response should be to massage the fundus to stimulate contraction of the uterus to compress open blood vessels at the placental site, limiting blood loss. The blood pressure is an important assessment to determine the extent of blood loss but is not the top priority. Notification should occur after all nursing measures have been attempted with no favorable results. The Trendelenburg position is contraindicated for this woman at this point. This position would not allow for appropriate vaginal drainage of lochia. The lochia remaining in the uterus would clot and produce further bleeding.
You might also like to view...
Registered nurses can be identified as a:
a. culture c. group b. subculture d. organization
Which nursing diagnosis would the nurse select for an older patient with asthma that has a respiratory rate of 28 and audible wheezes on inspiration?
1. Activity Intolerance 2. Altered Tissue Perfusion 3. Ineffective Airway Clearance 4. Ineffective Breathing Pattern with tachypnea and wheezing.
What information should the nurse coordinating an immunization program for health care workers and patients include?
A) Health care workers are at high risk for hepatitis B because of its airborne transmission. B) Immunization against hepatitis B involves a series of two injections given 6 months apart. C) The hepatitis B virus can't exist outside the body for more than a few minutes. D) Hepatitis B immunization should be given to neonates before they leave the hospital.
The nurse is assisting in a community health project for middle-aged adults attempting to identify which members of the community have been successful in the tasks identified by Erikson. The nurse look for the :?
1. Ability to have satisfaction in their volunteer activities 2. Ability to find an acceptable social group 3. Satisfaction with rearing children 4. Ability to manage a home