A nurse is assessing a client who delivered an infant vaginally 2 days ago and notes that the fundus is firm, midline, and at the level of the umbilicus, lochia rubra is moderate, and there are no clots present in the lochia flow.
Which of the following actions should the nurse take?
Document findings as normal
Massage fundus until it becomes firm
Administer oxytocin
Increase IV fluid rate
The Correct Answer is A
The correct answer is choice A) Document findings as normal.
The fundus is the upper part of the uterus that contracts after delivery to prevent bleeding. The fundus should be firm, midline, and at the level of the umbilicus or lower on the second postpartum day. Lochia rubra is the normal bloody discharge that occurs for the first few days after delivery and should not contain large clots. The normal range of lochia rubra is scant to moderate.
Choice B) Massage fundus until it becomes firm is wrong because the fundus is already firm and does not need further stimulation.
Choice C) Administer oxytocin (Pitocin) is wrong because oxytocin is a medication that helps the uterus contract and is not indicated for a firm fundus.
Choice D) Increase IV fluid rate is wrong because IV fluids are not related to the assessment of the fundus and lochia and may cause fluid overload.
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Correct Answer is B
Explanation
The correct answer is choice B. Palpate fundus.The nurse should first assess the tone of the uterus by palpating the fundus, as uterine atony is the most common cause of postpartum hemorrhage.
If the uterus is boggy or soft, the nurse should massage it gently until it becomes firm and contracts.
This will help control the bleeding from the placental site.
Choice A is wrong because assessing vital signs is not the first priority in this situation.Vital signs may not reflect the severity of blood loss until late in the process of hemorrhage.
The nurse should monitor vital signs after ensuring that the uterus is contracted.
Choice C is wrong because administering oxytocin as prescribed is not the first action the nurse should take.
Oxytocin is a medication that stimulates uterine contractions and reduces bleeding, but it should be given
Correct Answer is A
Explanation
The correct answer is choice A) Encourage fluid intake to promote hydration.
This is because hydration helps to flush out the infection and prevent dehydration from fever.
Fluid intake also supports milk production for breastfeeding.
Choice B) Instruct the client to avoid ambulation until symptoms resolve is wrong because ambulation promotes blood circulation and prevents thrombosis.
Ambulation also helps to expel lochia and reduce uterine cramping.
Choice C) Administer analgesics as prescribed to manage pain is correct but not the best answer.
Pain management is important for comfort and healing, but it does not address the underlying infection.
Choice D) Instruct the client to avoid breastfeeding until symptoms resolve is wrong because breastfeeding helps to contract the uterus and prevent bleeding.
Breastfeeding also provides immunity and nutrition to the newborn.
The infection is not transmitted through breast milk.
Choice E) Encourage frequent voiding is correct but not the best answer.
Frequent voiding helps to prevent urinary tract infections and bladder distension.
However, it does not directly affect the endometrial infection.
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