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 A
Explanation
This is a diagnostic procedure that involves inserting a needle into the uterus to obtain a sample of amniotic fluid for testing.
This procedure can cause a small amount of fetal blood to enter the maternal circulation, which can trigger an immune response in Rh-negative women carrying Rh-positive fetuses.
RhoGAM is a medication that contains antibodies against the Rh factor and prevents the mother from developing her own antibodies that could harm the fetus or future pregnancies.
RhoGAM should be given within 72 hours after amniocentesis to Rh-negative women who are not already sensitized2.
Choice B.
Biophysical Profile is incorrect, as this is a noninvasive diagnostic procedure that involves ultrasound and fetal heart rate monitoring to assess fetal well-being.
This procedure does not cause fetomaternal hemorrhage and does not require RhoGAM administration.
Choice C.
The contraction stress test is incorrect, as this is a noninvasive diagnostic procedure that involves inducing uterine contractions and monitoring fetal heart rate response to assess fetal oxygenation.
This procedure does not cause fetomaternal hemorrhage and does not require RhoGAM administration.
Choice D.
A nonstress test is incorrect, as this is a noninvasive diagnostic procedure that involves monitoring fetal heart rate and movement to assess fetal well-being.
This procedure does not cause fetomaternal hemorrhage and does not require RhoGAM administration.
Therefore, choice A is the best answer to this question.
Correct Answer is A
Explanation
This is a sign of uterine hyperstimulation, which can cause fetal distress and excessive bleeding12.
The nurse should report this finding to the provider and monitor the fetal heart rate and maternal vital signs.
Choice B.
Early decelerations in the FHR are incorrect, as this is a normal finding during the second stage of labor, indicating head compression.
Choice C.
Pelvic pressure with contractions is incorrect, as this is an expected finding during the second stage of labor, indicating that the baby is descending through the birth canal.
Choice D.
Bloody show from the vagina is incorrect, as this is also an expected finding during the second stage of labor, indicating cervical dilation and effacement13.
Therefore, choice A is the best answer.
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