A nurse is caring for a client who is 1 hr 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?.
Notify the client's provider.
Increase the frequency of fundal massage.
Document the findings and continue to monitor the client.
Encourage the client to empty her bladder.
The Correct Answer is C
The correct answer is choice C.
Choice A rationale:
Notifying the provider is not necessary in this case as the findings are normal for a client who is 1 hour postpartum.
Choice B rationale:
Increasing the frequency of fundal massage is not necessary as the fundus is firm and at the umbilicus.
Choice C rationale:
The findings are normal for a client who is 1 hour postpartum. The nurse should document the findings and continue to monitor the client. Therefore, this choice is correct.
Choice D rationale:
Encouraging the client to empty her bladder is not necessary in this case as the fundus is midline.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choice D.
Choice A rationale:
Cervix dilation of 5 cm with 50% effacement is a sign of active phase of the first stage of labor, not the end of it.
Choice B rationale:
Rupturing of fetal membranes can occur at any time during labor, not specifically at the end of the first stage.
Choice C rationale:
Start of regular contractions is a sign of the onset of labor, not the end of the first stage.
Choice D rationale:
Cervix dilation of 10 cm with 100% effacement indicates the end of the first stage of labor and the beginning of the second stage.
Correct Answer is D
Explanation
The correct answer is choice D.
Choice A rationale:
While oxytocin sensitivity is important for labor, there is no evidence to suggest that Braxton Hicks contractions increase oxytocin sensitivity.
Choice B rationale:
Prostaglandins play a crucial role in labor by causing the cervix to soften and dilate and the uterus to contract. However, there is no evidence to suggest that Braxton Hicks contractions increase the release of prostaglandins.
Choice C rationale:
While maternal comfort is important during labor, there is no evidence to suggest that Braxton Hicks contractions make maternal breathing easier.
Choice D rationale:
Braxton Hicks contractions help in softening and ripening the cervix, which is an important part of preparing for labor.
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