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.

Answer and Explanation

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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Correct Answer is A

Explanation

A. A fundus palpable to the right of midline may indicate a distended bladder pushing the uterus to the side, and it requires intervention to promote bladder emptying.
B. Less than 2.5 cm of rubra lochia on a perineal pad is a normal finding in the early postpartum period.
C. Increased thirst is not directly indicative of bladder distention.
D. Frequent uterine contractions are expected in the postpartum period and do not necessarily indicate bladder distention.

A. Ensure the infant breastfeeds in the first hour. B. Perform a glucose test for the infant before feeding. C. Administer intravenous dextrose infusion within 2 hours. D. Ensure the infant is fed every hour for the first 24 hours.

Correct Answer is A

Explanation

A. This intervention is correct because it provides the infant with a source of glucose and helps prevent hypoglycemia.
B. A glucose test alone may not provide timely intervention if hypoglycemia is detected.
C. Administering intravenous dextrose infusion is a rapid and effective way to address hypoglycemia, but early breastfeeding should be the priority action.
D. While frequent feeding is beneficial, intravenous dextrose may be necessary for a more immediate impact.

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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

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