How it Works
Try Naxlex NCLEX-RN (Free-Trial)

A nurse is assessing a client 1 hour after delivery and notices a large amount of lochia rubra along with several small clots on the perineal pad.
The client's fundus is firm and located at the umbilical level, in the midline.
What action should the nurse take next?

A.

Increase the frequency of fundal massage.

B.

Document the findings and continue to monitor the client.

C.

Notify the provider immediately.

D.

Encourage the client to empty her bladder.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Increasing fundal massage frequency is not necessary when the fundus is already firm and midline. Fundal massage is primarily used to address uterine atony, which is absent in this scenario. The findings indicate normal post-delivery uterine tone rather than a complication.

Choice B rationale

Documenting the findings and monitoring the client is appropriate when the fundus is firm and midline. The presence of small clots and a large amount of lochia rubra can be normal within the first hour postpartum. Continued observation ensures any potential issues are identified early.

Choice C rationale

Immediate notification of the provider is unnecessary unless there are signs of abnormal bleeding, uterine atony, or other complications. Since the fundus is firm and midline, this suggests the uterine tone is adequate, and intervention is not urgently needed.

Choice D rationale

Encouraging the client to empty her bladder is not relevant here, as the fundus is located appropriately at the midline and umbilical level, indicating that bladder distention is not affecting uterine position. This action would not address the described findings.


Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Free Nursing Study Resources

Related Questions

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"C"},"D":{"answers":"C"},"E":{"answers":"B"}}

Explanation

A. Formation of fingers, toes, and facial features

Correct Trimester: 1st Trimester (Conception – 13 weeks)
Explanation:
By the end of the 1st trimester, organogenesis (organ formation) is largely complete.

  • Weeks 7–8: Limb buds appear and begin differentiating into arms and legs.

  • Weeks 9–12: Fingers, toes, facial features (eyes, nose, lips, ears) become clearly defined.
    This is a critical period for congenital malformations if exposed to teratogens.

B. Fetus can hear and respond to external stimuli

Correct Trimester: 2nd Trimester (14–26 weeks)
Explanation:

  • Around 18–20 weeks: The fetus develops the ability to hear sounds.

  • External sounds can startle the fetus, and the heartbeat may change in response.

  • Mother's voice and music can be recognized at this stage.

C. Increase in body fat reserves

Correct Trimester: 3rd Trimester (27–40 weeks)
Explanation:

  • In the final trimester, especially after week 32, fat accumulates under the skin.

  • This provides energy and helps with temperature regulation after birth.

  • The fetus also gains the most weight during this period.

D. Brain develops most rapidly during this time

Correct Trimester: 3rd Trimester (27–40 weeks)
Explanation:

  • Although brain development starts early, the most rapid growth occurs in the third trimester.

  • There's a dramatic increase in brain volume, cortical folding, and neural connectivity.

  • This trimester is essential for cognitive and motor development.

E. Gender can be determined

Correct Trimester: 2nd Trimester (14–26 weeks)
Explanation:

  • By week 18–20, an ultrasound can reliably show external genitalia.

  • The sex organs begin forming in the 1st trimester, but become distinct and visible by the 2nd trimester.

  • This is when many parents find out the baby's gender via an anatomy scan.

Correct Answer is ["75"]

Explanation

Step 1 is (50 mg × 6 kg) ÷ 24 hours. The total daily dose calculates to 300 mg/day.

Step 2 is 300 mg ÷ 4 doses/day. Each dose calculates to 75 mg of Amoxicillin.

Final calculated dose per administration is 75 mg.

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Register