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.
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Naxlex Comprehensive Predictor Exams
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Correct Answer is D
Explanation
In patients with Duchenne muscular dystrophy (DMD), creatine kinase levels are often increased to levels that are 50-100 times the reference range.
Choice A is incorrect because lactate dehydrogenase is not typically elevated in DMD.
Choice B is incorrect because C-reactive protein is not typically elevated in DMD.
Choice C is incorrect because the erythrocyte sedimentation rate is not typically elevated in DMD.
Correct Answer is D
Explanation
On average, by 3 years of age, children can walk up and down stairs, one foot per step, with no support.
Choice A is incorrect because it is not developmentally appropriate for a 4-year-old child to place both feet on each step and hold on to the railing while descending stairs.
Choice B is incorrect because it is not developmentally appropriate for a 6-year-old child to place both feet on each step and hold on to the railing while descending stairs.
Choice C is incorrect because it is not developmentally appropriate for a 5-year-old child to place both feet on each step and hold on to the railing while descending stairs.
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