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. Breast milk typically comes in 3 to 5 days postpartum.
B. This timeline is too early for the onset of mature breast milk.
C. This timeline is too late for the onset of mature breast milk.
D. This timeline is too late for the onset of mature breast milk.

A. “I will use mild soap.” B. “I will test the water on my wrist for temperature before bathing.” C. “Baby powder will help prevent a diaper rash.” D. “I will use a basin during bathing.”

Correct Answer is C

Explanation

A. Using mild soap is a suitable practice for newborn skin care.
B. Testing water temperature before bathing is a safety measure to prevent burns.
C. Baby powder is not recommended for newborns as it can cause respiratory issues when inhaled.
D. Using a basin during bathing is a reasonable approach to facilitate safe and controlled bathing.

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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 postpartum who asks the nurse when her breast milk will "come in." Which of the following responses should the nurse make?

Correct Answer is A

Explanation

A nurse is reinforcing teaching about newborn care with a postpartum client. Which of the following statements by the client indicates a need for further teaching?

Correct Answer is C

Explanation

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