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?
Increase the frequency of fundal massage.
Document the findings and continue to monitor the client.
Notify the provider immediately.
Encourage the client to empty her bladder.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C"]
Explanation
Choice A rationale
Interviewing the client privately ensures confidentiality and allows for honest disclosure of the situation without fear of intimidation or manipulation by accompanying individuals. This approach is critical in identifying domestic abuse victims and initiating proper interventions.
Choice B rationale
A calm, caring, and professional demeanor fosters trust and reduces the client’s anxiety or fear. It ensures the nurse-patient relationship is non-threatening, encouraging the teen to open up about her experiences and facilitating accurate assessment and care.
Choice C rationale
Assessing whether the teen feels safe helps identify her immediate risks and the presence of a potential threat. Recognizing unsafe living conditions enables the nurse to involve appropriate protective and social services to ensure the client’s safety.
Choice D rationale
Contacting the police should be done only with the client’s consent unless mandated by law. Immediate police involvement without consent may jeopardize the client’s trust in the healthcare system and compromise her willingness to seek help in the future.
Correct Answer is D
Explanation
Choice A rationale
Frequent cervical assessments increase the risk of introducing pathogens into the reproductive tract, especially with premature rupture of membranes (PROM). Continuous assessments are unnecessary unless labor is progressing or there are indications of infection. PROM exposes the fetus to potential infections like chorioamnionitis, and invasive procedures should be minimized to reduce infection risk.
Choice B rationale
Preparing for delivery is not a priority intervention unless signs of labor or fetal distress occur. At 32 weeks, preterm delivery poses significant risks, including respiratory distress syndrome and intraventricular hemorrhage. The goal is to prolong pregnancy to improve neonatal outcomes while closely monitoring the client for complications. Immediate delivery is reserved for emergent situations.
Choice C rationale
Providing emotional support is essential but does not directly address the risk of infection associated with PROM. While psychological support is beneficial, it is secondary to interventions aimed at preventing infection, which is the primary concern. Emotional well-being should complement, not replace, medical interventions.
Choice D rationale
Administering parenteral antibiotics helps prevent infection in cases of PROM, particularly when membranes rupture prematurely and expose the fetus to pathogens. Early antibiotic treatment reduces the risk of ascending infections like chorioamnionitis and neonatal sepsis. This intervention is crucial to protect maternal and fetal health during prolonged PROM.
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