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. The baby should be carried in the parent’s arms from the room to the nursery B. The mom should request that a second staff member verify the identity of any questionable person C. Because of infant security systems, the baby can be left unattended in the client’s room D. Parents should be told it is safe to posting photographs of their infant on the Internet

Correct Answer is B

Explanation

A. Carrying the baby in the parent's arms enhances security but does not directly address the prevention of abduction.
B. Verifying the identity of any questionable person by a second staff member is a key measure to prevent infant abduction.
C. Leaving the baby unattended in the client's room is not a safe practice and does not contribute to preventing abduction.
D. Posting photographs of the infant on the Internet can compromise the child's security and is not recommended.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is 2 hr postpartum following a vaginal birth. Which of the following findings indicates the client's bladder is distended?

Correct Answer is A

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Correct Answer is B

Explanation

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