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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Related Questions
Correct Answer is D
Explanation
A. Vernix caseosa is a white, cheese-like substance covering the baby's skin.
B. Erythema toxicum neonatorum is a benign rash that appears in the early days of life.
C. Harlequin sign is a transient color change in a newborn, not related to blue hands and feet.
D. Acrocyanosis is a common and temporary condition where the hands and feet may appear blue due to poor peripheral circulation. It is not typically a sign of coldness.
Correct Answer is A
Explanation
A. Prolactin remains elevated in the immediate postpartum period of breastfeeding women to stimulate milk production.
B. Progesterone levels decrease rapidly after childbirth.
C. Estrogen levels decrease in the postpartum period, particularly during breastfeeding.
D. Human Placental Lactogen (HPL) levels decrease after childbirth.
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