The nurse notes that the fundus of a postpartum patient is boggy, shifted to the left of the midline, and 2 cm above the umbilicus. What is the nurse's priority action?

Correct Answer: A

Rationale: The nurse's priority action when the fundus is not firm is to massage it until it becomes firm and to express any clots that may have accumulated. This helps the uterus contract effectively. Other actions such as assisting the patient to void, increasing oxytocin infusion, or bringing in a straight catheter tray are not the immediate priority in this situation.

Correct Answer: C

Rationale: The nurse should suspect craniosynostosis (premature closing of sutures) and therefore should contact the pediatric provider immediately. The physical findings do not align with a strenuous birth process, and monitoring is not the appropriate initial action. It is important to note the presence of fontanels, but the immediate action should be to seek medical intervention.

Correct Answer: B

Rationale: The correct answer is B because questioning anyone seen walking in the hallways carrying an infant is a proactive measure to prevent newborn abduction. It is important to be vigilant and question individuals who do not have proper authorization or identification when carrying an infant. Restricting the time infants are out of the nursery and monitoring visitors are also important measures to prevent abduction.

Correct Answer: B

Rationale: When an infant's temperature drops, it may be caused by a decrease in blood glucose levels. Therefore, determining the time and amount of the last feeding is crucial to address the underlying issue. Instructing parents on cold stress and increasing room temperature are interventions to maintain a stable temperature but will not address the root problem. A blood sugar level higher than 50 mg/dL is actually a normal finding in infants.

Correct Answer: C

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.