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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Related Questions
Correct Answer is D
Explanation
A. Applying an ice pack may provide temporary relief from pain and swelling, but in this case, since the pain is unrelieved, a warm sitz bath would be more appropriate to promote relaxation and healing of the perineal area.
B. Applying a hot pack to the perineum may increase inflammation and discomfort rather than providing relief.
C. Providing a squeeze bottle of antiseptic solution may help with perineal hygiene but will not directly address the unrelieved pain from the episiotomy.
D. Offering a warm sitz bath can help soothe the perineal area, promote healing, and provide relief from episiotomy pain by increasing blood flow to the area and relaxing the muscles.
Correct Answer is C
Explanation
A. Placing the baby on his stomach increases the risk of sudden infant death syndrome (SIDS) and is not recommended.
B. Placing the crib next to the heater can increase the risk of overheating and is not safe.
C. Removing extra blankets from the baby's crib reduces the risk of suffocation and entanglement, promoting a safe sleep environment.
D. Padding the mattress in the baby's crib can increase the risk of suffocation and is not recommended.
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