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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
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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