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. Preterm delivery may result in a newborn being small for gestational age, but it is not the primary cause of this condition.
B. Fetal hyperinsulinemia may contribute to macrosomia (large for gestational age) rather than small for gestational age.
C. Perinatal asphyxia may lead to intrauterine growth restriction but is not a primary cause of being small for gestational age.
D. Placental insufficiency is a common cause of intrauterine growth restriction and results in inadequate nutrient and oxygen delivery to the fetus, leading to a newborn being small for gestational age.
Correct Answer is A
Explanation
A. Drying the newborn's skin thoroughly helps to reduce evaporative heat loss by removing moisture from the skin's surface, which decreases heat loss through evaporation.
B. Maintaining ambient room temperature at 24°C (75°F) helps to prevent hypothermia but does not directly address evaporative heat loss.
C. Preventing air drafts is important for reducing convective heat loss but does not specifically target evaporative heat loss.
D. Placing the newborn on a warm surface helps to prevent conductive heat loss but does not directly address evaporative heat loss.
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