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?
Document the findings and continue to monitor the client.
Encourage the client to empty her bladder.
Increase the frequency of fundal massage.
Notify the client’s provider.
The Correct Answer is A
A. The presence of lochia rubra with small clots in the immediate postpartum period is expected. The firm and midline fundus indicates appropriate uterine contraction. Continued monitoring is appropriate.
B. Encouraging the client to empty her bladder is a valid intervention, but it is not the priority in this situation.
C. Increasing the frequency of fundal massage is unnecessary, as the fundus is already firm.
D. Notifying the provider is not necessary based on the described findings, as they are within the expected range.
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Related Questions
Correct Answer is D
Explanation
A. Soft and non-tender breasts are a normal finding in the early postpartum period.
B. A urine output of 3,000 mL in 12 hours is within the normal range.
C. A fundus palpable at the umbilicus may be normal within the first few hours after childbirth.
D. A heart rate of 128/min may indicate a postpartum complication, such as hemorrhage or infection, and requires further assessment.
Correct Answer is A
Explanation
A. Proper latch involves placing both the nipple and a portion of the areola into the baby's mouth.
B. While babies have instincts, guidance on proper latch is essential for successful breastfeeding.
C. Placing the nipple and areola under the tongue is not accurate guidance for breastfeeding.
D. Limiting the latch to part of the nipple may lead to ineffective breastfeeding.
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