A nurse is caring for a client who is 4 hours postpartum.
The nurse finds a small amount of lochia rubra on the client's perineal pad, and the fundus is midline and firm at the
umbilicus.
Which of the following actions should the nurse take?
Assist the client to ambulate
Perform fundal massage
Increase the rate of the IV fluids
Check for blood under the client's buttocks
The Correct Answer is D
Choice A rationale:
Assisting the client to ambulate is not the immediate action required in this scenario. The nurse has found a small amount of
lochia rubra on the client’s perineal pad, and the fundus is midline and firm at the umbilicus. These are normal findings for a
client who is 4 hours postpartum. However, the nurse should ensure that there is no excessive bleeding, which could be a sign
of postpartum hemorrhage.
Choice B rationale:
Performing a fundal massage is not necessary in this case. Fundal massage is usually performed when the uterus is boggy or
soft, which could indicate uterine atony, a leading cause of postpartum hemorrhage. In this scenario, the fundus is firm and at
the level of the umbilicus, which is a normal finding 4 hours postpartum.
Choice C rationale:
Increasing the rate of IV fluids is not the immediate action required in this scenario. IV fluids are usually increased to expand
intravascular volume in cases of postpartum hemorrhage. In this case, the nurse has found a small amount of lochia rubra on
the client’s perineal pad, which is a normal finding 4 hours postpartum.
Choice D rationale:
Checking for blood under the client’s buttocks is the correct action for the nurse to take in this scenario. This is to ensure that
there is no excessive bleeding, which could be hidden under the client’s buttocks. Excessive bleeding could be a sign of
postpartum hemorrhage, a potentially life-threatening complication.
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Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Placing a soft pillow under the client's buttocks is not recommended for episiotomy pain relief. It can actually increase pain by placing pressure on the perineum and impeding blood flow to the area. This can hinder healing and prolong discomfort.
Additionally, it can separate the buttocks, potentially decreasing venous return and further exacerbating pain.
Choice C rationale:
Positioning a heating lamp toward the episiotomy is not appropriate within the first 24 hours following delivery. Heat application during this early stage can increase inflammation and swelling, potentially worsening pain and delaying healing.
Heat therapy is typically recommended after 24 hours to promote circulation and tissue repair, but it's crucial to apply it at the appropriate time.
Choice D rationale:
Preparing a warm sitz bath is a common comfort measure for postpartum perineal care, but it's generally recommended after
Correct Answer is A
Explanation
Choice A rationale:
Umbilical cord compression is a serious condition that can deprive the fetus of oxygen and nutrients. It can occur during labor
due to various factors, such as excessive fetal movement, a long umbilical cord, or decreased amniotic fluid.
Key signs of umbilical cord compression include:
Variable decelerations: These are abrupt decreases in the fetal heart rate (FHR) that vary in duration, depth, and timing. They
are often caused by cord compression, as the compression temporarily reduces blood flow to the fetus.
Late decelerations: These are delayed decreases in the FHR that occur after the peak of a uterine contraction. They can also be
a sign of cord compression, as the compression can impair placental blood flow.
Loss of FHR variability: This refers to a decrease in the normal fluctuations of the FHR. It can be a sign of fetal distress,
including cord compression.
Immediate action is crucial when umbilical cord compression is suspected. The nurse should:
Notify the provider immediately.
Change the mother's position: This can help relieve pressure on the cord. Common positions include:
Lateral positioning (lying on the side)
Trendelenburg position (lying on the back with the head tilted down)
Knee-chest position (kneeling with the chest on the bed)
Administer oxygen to the mother: This can increase fetal oxygenation.
Prepare for possible interventions: These may include amnioinfusion (infusing fluid into the amniotic sac to increase fluid
volume), internal fetal monitoring, or cesarean delivery.
Choice B rationale:
Head compression is a common occurrence during labor as the fetal head descends through the birth canal. It usually does not
require intervention unless it causes significant changes in the FHR or other signs of fetal distress.
Choice C rationale:
Maternal opioid administration can affect the FHR, but it is not typically a cause for immediate concern unless there are
significant changes in the FHR or other signs of fetal distress. The nurse should continue to monitor the FHR closely and report
any concerns to the provider.
Choice D rationale:
Lateral decelerations are not a recognized pattern of fetal heart rate decelerations. The correct term for decelerations that
occur after the peak of a contraction is "late decelerations."
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