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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choice D. At the level of the umbilicus.
Choice A rationale:
The uterine fundus is not typically found to the right of the umbilicus after delivery.
Choice B rationale:
The uterine fundus is not typically found 2 cm above the umbilicus after delivery.
Choice C rationale:
The uterine fundus is not typically found one fingerbreadth above the symphysis pubis after delivery.
Choice D rationale:
After delivery, the uterine fundus is typically found at the level of the umbilicus.
Correct Answer is B
Explanation
The correct answer is choice B.
Choice A rationale:
Massaging the uterus does not increase its boggy nature, but rather helps it contract and become firm, reducing the risk of postpartum hemorrhage.
Choice B rationale:
Massaging the uterus helps constrict the uterine blood vessels, which reduces bleeding after the placenta has been expelled.
Choice C rationale:
Massaging the uterus has no effect on the likelihood of conducting an episiotomy, which is a surgical incision made during childbirth.
Choice D rationale:
Massaging the uterus does not remove pieces left attached to the uterine wall. This would require a manual or surgical procedure.
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