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. When the cervix is fully dilated.
Choice A rationale:
The arrival of the health care provider does not determine when the laboring client should push. This is dependent on the dilation of the cervix.
Choice B rationale:
Seeing the fetal head is not the determinant for when the laboring client should push. The cervix needs to be fully dilated.
Choice C rationale:
The nurse wanting the client to push is not the correct time for the laboring client to push. The cervix needs to be fully dilated.
Choice D rationale:
The laboring client is encouraged to push when the cervix is fully dilated. This is to avoid birth trauma.
Correct Answer is C
Explanation
The correct answer is choice C.
Choice A rationale:
Generalized vasospasm is not a symptom of abruptio placenta. It is more associated with conditions like preeclampsia.
Choice B rationale:
Abruptio placenta is usually associated with painful dark red vaginal bleeding, not painless bright red bleeding.
Choice C rationale:
“Knife-like” abdominal pain with vaginal bleeding is a classic symptom of abruptio placenta.
Choice D rationale:
Increased fetal movement is not a symptom of abruptio placenta. In fact, fetal movement may decrease due to distress.
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