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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. The radiant heat warmer does not prevent brown fat production, which is a normal response to cold exposure in newborns.
B. Shivering is a response to cold and not prevented by the radiant heat warmer.
C. The radiant heat warmer helps prevent cold stress by maintaining the newborn's body temperature.
D. Basal metabolic rate reduction is not a specific concern addressed by the radiant heat warmer.
Correct Answer is B
Explanation
A. The introduction of solid food is recommended at similar times for both breastfed and formula-fed infants.
B. The AAP recommends exclusive human milk feeding for the first 6 months of life.
C. After 6 months, complementary foods are introduced, not a shift to cow's milk.
D. If weaned before 12 months, formula is a suitable alternative to breast milk.
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