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

Answer and Explanation

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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Correct Answer is C

Explanation

Choice C rationale:

Monitoring contraction frequency is essential to assess the progression of labor. Contractions are the tightening and relaxing of the uterine muscles that help to dilate the cervix and push the baby down the birth canal. The frequency of contractions is measured in minutes from the beginning of one contraction to the beginning of the next. As labor progresses, contractions become more frequent, regular, and intense. Monitoring contraction frequency helps the nurse to determine the stage of labor, assess the effectiveness of interventions, and identify any potential complications.

Monitoring fetal heart rate is crucial to assess the well-being of the baby during labor. The fetal heart rate is normally between 110 and 160 beats per minute. A normal fetal heart rate indicates that the baby is getting enough oxygen and is not in distress. Variations in the fetal heart rate, such as decelerations or tachycardia, can indicate potential problems and may require intervention.

Choice A rationale:

Preterm labor is defined as labor that begins before 37 weeks of gestation. The client in this scenario is at 38 weeks of gestation, which is considered term. Therefore, preterm labor is not the most likely condition.

Choice B rationale:

The administration of medication and bed rest may be appropriate interventions for preterm labor, but they are not the most appropriate interventions for a client in labor at 38 weeks of gestation. At this stage of pregnancy, labor is considered to be full-term, and interventions are focused on supporting the normal labor process and ensuring the safety of the mother and baby.

A. Check the client’s fundus B. Request the provider perform a vaginal examination C. Measure the client’s vital signs D. Check for a full bladder

Correct Answer is B

Explanation

Rationale for Choice A:

Checking the client's fundus is an important assessment in the postpartum period, but it is not the most immediate action

when a large amount of lochia rubra with clots is present. A boggy or displaced fundus could indicate subinvolution or

hemorrhage, but these are not the most likely causes of the presenting symptoms.

Rationale for Choice B:

Performing a vaginal examination is the most appropriate first action in this situation. This will allow the nurse to directly

assess the source and amount of bleeding, as well as to check for any retained placental fragments or cervical lacerations.

These findings could be the cause of the lochia rubra and clots, and prompt intervention may be necessary.

Rationale for Choice C:

While measuring the client's vital signs is an important part of the postpartum assessment, it is not the most immediate action

when there is evidence of active bleeding. Taking vital signs can be delayed while the nurse performs a vaginal examination to

assess the source and severity of the bleeding.

Rationale for Choice D:

Checking for a full bladder is not the most relevant action in this situation. A full bladder can contribute to postpartum

discomfort, but it is not likely to be the cause of the lochia rubra and clots. Addressing the bleeding should be the priority.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting in the care of a client who is at 38 weeks of gestation. What condition is the client most likely experiencing, what are 2 actions the nurse should take to address that condition, and what are 2 parameters the nurse should monitor to assess the client’s progress?

Correct Answer is C

Explanation

Choice C rationale:

Choice A rationale:

Choice B rationale:

A nurse is collecting data from a postpartum client and finds a large amount of lochia rubra with several clots on the client’s perineal pad.Which of the following actions should the nurse take first?

Correct Answer is B

Explanation

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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?