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 D
Explanation
The correct answer is choice D. Chronic alcohol use.
Choice A rationale:
Active herpes simplex infection during pregnancy can lead to neonatal herpes, which is a serious condition, but it does not cause the symptoms described.
Choice B rationale:
Chronic cocaine use during pregnancy can lead to premature birth and low birth weight, but it does not typically result in the specific symptoms described.
Choice C rationale:
Folic acid deficiency during pregnancy can lead to neural tube defects, which can cause a range of symptoms, but not the specific ones described.
Choice D rationale:
Chronic alcohol use during pregnancy can lead to Fetal Alcohol Syndrome, which includes slow growth, cognitive and intellectual deficits, and the facial abnormalities described.
Correct Answer is B
Explanation
The correct answer is choice B.
Choice A rationale:
Stimulating the infant to cry is important, but it is not the first action to be taken.
Choice B rationale:
Clearing the respiratory tract is the first action to be taken to ensure the newborn can breathe properly.
Choice C rationale:
Drying the infant off and covering the head is done after the respiratory tract is cleared.
Choice D rationale:
Cutting the umbilical cord is done after the infant is stabilized.
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