A nurse is caring for a client who is 4 hr postpartum.
The nurse finds a small amount of lochia rubra on the client's perineal pad.
The fundus is midline and firm at the umbilicus.
Which of the following actions should the nurse take?
Assist the client to ambulate.
Increase the rate of IV fluids.
Check for blood under the client's buttock.
Perform fundal massage.
The Correct Answer is C
The nurse should check for blood under the client’s buttocks.
A small amount of lochia rubra on the client’s perineal pad 4 hours postpartum is normal.
The fundus being midline and firm at the umbilicus is also a normal finding.
Choice A is incorrect because assisting the client to ambulate is not necessary at this time.
Choice B is incorrect because there is no need to increase the rate of IV fluids.
Choice D is incorrect because performing a fundal massage is not necessary since the fundus is already firm and midline.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
By 3 months old, most babies can lift their heads and chest up from a belly-down position.
Choice A is not correct because it is normal for a 3-month-old infant to be unable to roll from back to abdomen.
Choice B is not correct because it is normal for a 3-month-old infant to be unable to use a pincer grasp to pick up objects.
Choice D is not correct because it is normal for a 3-month-old infant to be unable to sit without support.
Correct Answer is D
Explanation
Fever is a sign of infection and can indicate that there is an infection at the pin sites.
Choice A is not correct because warmth can be a normal finding at the pin sites.
Choice B is not correct because mild erythema can be a normal finding at the pin sites.
Choice C is not correct because serosanguineous drainage can be a normal finding at the pin sites.
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