A nurse is caring for a client who is 1 hour postpartum and observes a large amount of lochia rubra and several small clots on the client's perineal pad. The fundus is midline and firm at the umbilicus. Which of the following actions should the nurse take?
Document the findings and continue to monitor the client.
Increase the frequency of fundal massage.
Encourage the client to empty her bladder.
Notify the client's provider.
The Correct Answer is A
A. The findings described are within the expected range for 1 hour postpartum, as lochia rubra and small clots are normal during the early postpartum period. The firm, midline fundus suggests adequate uterine contraction. Documenting the findings and continuing to monitor the client's progress are appropriate.
B. Increasing the frequency of fundal massage is not necessary as the fundus is already firm and midline.
C. Encouraging the client to empty her bladder is important for uterine involution, but it is not the priority in this scenario, as the fundus is already firm and midline.
D. Notifying the client's provider is not necessary at this time, as the findings are within the expected range for the early postpartum period and do not indicate any immediate complications.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Applying ice packs to the breasts after feeding can help reduce swelling and discomfort associated with breast engorgement.
B. Applying hot packs to the breasts during feeding can increase blood flow and exacerbate engorgement. Heat can worsen inflammation and discomfort in the breasts.
C. Crushed cabbage leaves can be applied to the breasts between feedings to help reduce swelling and discomfort associated with engorgement.
D. Breastfeeding every 2 hours helps to ensure frequent emptying of the breasts, which can help alleviate engorgement.
Correct Answer is D
Explanation
A. A white patch on a nipple may indicate a fungal infection such as thrush but is not typically associated with mastitis.
B. Cracked and bleeding nipples are common in breastfeeding but are not specific to mastitis.
C. Swelling in both breasts can occur with engorgement but is not indicative of mastitis, which typically presents with localized symptoms.
D. A red and painful area in one breast is a classic sign of mastitis. Mastitis is an infection of the breast tissue that often presents with localized redness, warmth, swelling, and pain in one breast. Other symptoms may include fever, chills, and flu-like symptoms.
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