If a woman's fundus is soft 30 minutes after birth, the nurse's ...

[123654777]

If a woman's fundus is soft 30 minutes after birth, the nurse's first response should be to
 
  a. Take the blood pressure.
  b. Massage the fundus.
  c. Notify the physician or nurse-midwife.
  d. Place the woman in Trendelenburg position.

Question 2

During oxytocin induction, the fetal heart rate shows marked decelerations. What action should the nurse take first?
 
  a. Administer oxygen via face mask.
  b. Turn client to the left side-lying position.
  c. Turn off the Pitocin drip.
  d. Increase IV fluids.

[apple]

Answer to Question 1

B
Feedback
A The blood pressure is an important assessment to determine the extent of blood
loss, but it is not the top priority.
B 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.
C Notification should occur after all nursing measures have been attempted with no
favorable results.
D Trendelenburg position is contraindicated for this woman at this point. This
position does not allow for appropriate vaginal drainage of lochia. The lochia
remaining in the uterus would clot and produce further bleeding.

Answer to Question 2

C
Oxytocin can produce marked fetal decelerations that could lead to fetal distress, so turning off the Pitocin is the appropriate first action. While administering oxygen via face mask is appropriate, it is not the first action the nurse should take. Turning the client to the left side-lying position is an appropriate nursing action, but it is not specific to oxytocin-induced fetal decelerations.