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 B
Explanation
A. While visual attention to the speaker is a positive sign, routine hearing screenings provide a more accurate assessment of hearing.
B. Routine hearing screenings are conducted on newborns to identify hearing issues early, allowing for intervention if necessary.
C. While most forms of hearing loss may not be inherited, it's important to assess the newborn's hearing through appropriate screenings.
D. Startle reflex is not a reliable indicator of hearing ability, and routine screenings provide more accurate information.
Correct Answer is ["50"]
Explanation
To calculate the infusion rate for antibiotic X, the nurse needs to use the formula: gtt/min = (Volume x Drop factor) / Time
Plugging in the values from the question, we get:
gtt/min = (50 mL x 20 gtt/mL) / 20 min Simplifying, we get:
gtt/min = 1000 gtt / 20 min Dividing, we get:
gtt/min = 50 gtt/min
Therefore, the nurse should set the manual IV infusion to deliver 50 gtt/min.
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