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 A
Explanation
The correct answer is choice A.
Choice A rationale:
The glucose challenge test is used to check for gestational diabetes during pregnancy. People at average risk of gestational diabetes usually have this test done during the second trimester, generally between 24 and 28 weeks of pregnancy.
Choice B rationale:
This is too early in the pregnancy to screen for gestational diabetes. The body’s response to sugar changes as the pregnancy progresses, so testing is typically done later.
Choice C rationale:
This is still a bit early for the screening. The recommended time is between 24 and 28 weeks of gestation.
Choice D rationale:
This is too late in the pregnancy for the screening. The recommended time is between 24 and 28 weeks of gestation.
Correct Answer is B
Explanation
The correct answer is choice B.
Choice A rationale:
Cabbage leaves have been used for many years for relief of breast engorgement. They can be crushed slightly until the juice is visible and then chilled in the refrigerator before applying to the breasts.
Choice B rationale:
Applying hot packs during feeding can actually increase blood flow and make engorgement worse. Cold packs should be used after feeding to help reduce swelling.
Choice C rationale:
Applying ice packs after feeding can help reduce swelling and provide relief from engorgement.
Choice D rationale:
Frequent breastfeeding can help to relieve engorgement. The breasts should be emptied completely at each feeding.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.