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.

Answer and Explanation

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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Correct Answer is A

Explanation

A. The fundus palpable to the right of midline suggests that the bladder is distended and pushing the uterus to the right, displacing it from its expected midline position.
B. Less than 2.5 cm of rubra lochia on the perineal pad is a normal amount of lochia for 2 hours postpartum and does not necessarily indicate bladder distention.
C. Client report of frequent uterine contractions may indicate uterine involution but does not directly assess bladder distention.
D. Client report of increased thirst may indicate dehydration but does not directly assess bladder distention.

A. Absent plantar reflexes B. Lengthened thigh on the affected side C. Asymmetric thigh folds D. Inwardly turned foot on the affected side

Correct Answer is C

Explanation

A. Absent plantar reflexes may indicate neurological issues but are not specifically associated with developmental dysplasia of the hip (DDH).
B. Lengthened thigh on the affected side is not a typical finding in DDH. Instead, there may be apparent shortening due to hip dislocation.
C. Asymmetric thigh folds are a common finding in DDH due to hip instability, causing the femoral head to be displaced from the acetabulum and resulting in uneven thigh folds.

D. An inwardly turned foot on the affected side may be seen in conditions like clubfoot but is not a characteristic finding in DDH.

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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?

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