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 B

Explanation

A. Placing an identification bracelet is important but not the immediate priority after ensuring a patent airway.
B. Drying the skin is a priority to prevent heat loss and promote thermoregulation in the newborn.
C. Administering vitamin K is important but can be done after drying the skin.
D. Administering eye prophylaxis is important but can be done after drying the skin.

Correct Answer is ["120"]

Explanation

To calculate the infusion rate in gtt/min, the nurse needs to use the formula: gtt/min = (mL/hr x drop factor) / 60

Plugging in the given values, we get:

gtt/min = (120 mL/hr x 60 gtt/mL) / 60

gtt/min = 7200 gtt/hr / 60 gtt/min = 120 gtt/min

Therefore, the nurse should set the manual IV infusion to deliver 120 gtt/min.

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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 newborn immediately following birth. After assuring a patent airway, what is the priority nursing action?

Correct Answer is B

Explanation

Correct Answer is ["120"]

Explanation

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