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 B
Explanation
The correct answer is choice B.
Choice A rationale:
Focus on the family unit and its members is more characteristic of the “letting-go” phase.
Choice B rationale:
Expressions of excitement are common in the dependent, taking in phase as the mother is focused on her own needs and the experience of childbirth.
Choice C rationale:
Eagerness to learn newborn care skills is more characteristic of the “taking-hold” phase.
Choice D rationale:
Lack of appetite is not a typical characteristic of the dependent, taking in phase.
Correct Answer is A
Explanation
The correct answer is choice A.
Choice A rationale:
An internal examination could disturb the placenta and cause profound bleeding, which is a life-threatening condition for both the mother and the fetus.
Choice B rationale:
While there is always a risk of introducing infection during an internal examination, this is not the primary reason to avoid it in a client with placenta previa.
Choice C rationale:
An internal examination could potentially initiate preterm labor, but this is not the primary concern with placenta previa.
Choice D rationale:
While there is a risk of rupture of the amniotic membranes during an internal examination, this is not the primary reason to avoid it in a client with placenta previa.
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