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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.

Answer and Explanation

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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Correct Answer is B

Explanation

The correct answer is choice B.

Choice A rationale:

Vitamin K is given to newborns to prevent bleeding disorders, not eye conditions.

Choice B rationale:

Erythromycin ophthalmic ointment is commonly used for prophylaxis of neonatal conjunctivitis (pink eye) caused by Neisseria gonorrhoeae and Chlamydia trachomatis.

Choice C rationale:

Gentamicin ophthalmic ointment can be used to treat bacterial infections of the eye, but it is not typically used for prophylaxis of neonatal eye conditions.

Choice D rationale:

Silver nitrate solution was once used for prophylaxis of neonatal eye conditions, but it is no longer commonly used due to the risk of chemical conjunctivitis.

A. There is a loss of 5% to 10% of the birth weight in the first few days in breastfed infants only. B. There is an increase in 3% to 5% of birth weight by day 3 in formula-fed babies. C. There is a loss of 5% to 10% of birth weight in formula-fed and breastfed newborns. D. A formula-fed newborn should gain 3% to 5% of the initial birth weight in the first 48 hours, but a breastfed newborn may lose up to 3%.

Correct Answer is C

Explanation

The correct answer is choice C.

Choice A rationale:

While it’s true that breastfed infants may lose 5% to 10% of their birth weight in the first few days, this is not exclusive to breastfed infants.

Choice B rationale:

Formula-fed babies may gain weight more quickly than breastfed babies, but they do not typically show an increase in weight by day 3.

Choice C rationale:

Both formula-fed and breastfed newborns can lose 5% to 10% of their birth weight in the first few days.

Choice D rationale:

While formula-fed newborns may gain weight more quickly than breastfed newborns, they do not typically gain 3% to 5% of the initial birth weight in the first 48 hours.

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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?.

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Naxlex Comprehensive Predictor Exams

In an effort to decrease complications for the infant right after birth, the nurse would expect to administer which medication for prophylaxis of potential eye conditions?.

Correct Answer is B

Explanation

What should the nurse expect for a full-term newborn's weight during the first few days of life?.

Correct Answer is C

Explanation

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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?.