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:
Variable decelerations are associated with problems with the umbilical cord, such as compression. This is because they occur irregularly and can happen at any time during the contraction cycle.
Choice B rationale:
Early decelerations are usually benign and are associated with fetal head compression during a uterine contraction. They are not typically indicative of a problem with the umbilical cord.
Choice C rationale:
Accelerations are usually a sign of fetal well-being and are not typically associated with umbilical cord issues.
Choice D rationale:
Late decelerations are associated with uteroplacental insufficiency, which is a decrease in the blood flow to the placenta that reduces the amount of oxygen and nutrients transferred to the fetus. They are not typically indicative of a problem with the umbilical cord.
Correct Answer is []
Explanation
The correct answer is “At 0 station”.
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.