A nurse is caring for a client who delivered an infant vaginally 2 days ago and notes that there are no clots present in the lochia flow, but there is moderate bleeding with bright red blood and small clots present when massaging the fundus which is firm, midline, and at the level of the umbilicus.
Document findings as normal
Massage fundus until it becomes firm
Administer oxytocin
Increase IV fluid rate
The Correct Answer is C
The correct answer is choice C) Administer oxytocin (Pitocin). Oxytocin is a hormone that stimulates uterine contractions and helps reduce postpartum bleeding by closing off the blood vessels that were attached to the placenta.
The nurse should administer oxytocin as ordered by the provider to help the client’s uterus contract and prevent hemorrhage.
Choice A) Document findings as normal is wrong because moderate bleeding with bright red blood and small clots is not normal for lochia flow 2 days after delivery. Lochia is the vaginal discharge that occurs after birth and consists of blood, tissue, mucus and bacteria. Lochia should be dark or bright red for the first 3 to 4 days, but the flow should be light and there should be no clots. Moderate bleeding with bright red blood and small clots indicates that the client may have retained placental fragments or uterine atony.
Choice B) Massage fundus until it becomes firm is wrong because the fundus is already firm, midline and at the level of the umbilicus, which indicates that the uterus is contracted properly. Massaging the fundus when it is already firm can cause more bleeding and pain.
Choice D) Increase IV fluid rate is wrong because increasing IV fluid rate will not stop the bleeding or address the underlying cause. Increasing IV fluid rate may also cause fluid overload or dilutional coagulopathy. The nurse should monitor the client’s vital signs, urine output and hematocrit levels to assess for signs of hypovolemia or anemia due to blood loss.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is A
Explanation
The correct answer is choice E) Signs of peritonitis.
Peritonitis is an inflammation of the lining of the abdominal cavity that can be caused by an infection or a perforation of an organ.
It can cause severe abdominal pain and tenderness, fever, nausea, vomiting, and decreased bowel sounds.Peritonitis is a medical emergency that requires immediate treatment with antibiotics and surgery
Choice A) Bowel sounds is wrong because bowel sounds are normal and expected after a cesarean section.
They indicate that the intestines are functioning properly and moving food and gas through the digestive tract.Bowel sounds may be decreased or absent if there is an obstruction, ileus, or peritonitis
Choice B) Lochia amount is wrong because lochia is the vaginal discharge that occurs after childbirth.
It consists of blood, mucus, and tissue from the uterus.
Lochia amount is not related to abdominal pain and tenderness after a cesarean section.
Lochia amount may vary depending on the stage of lochia (rubra, serosa
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