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
Related Questions
Correct Answer is B
Explanation
During pregnancy, a woman needs to increase her caloric intake by approximately 300 extra calories per day.
These extra calories should come from a balanced diet of protein, fruits, vegetables, and whole grains.
Choice A is incorrect because adding an additional 500 calories/day by drinking milkshakes is not a healthy way to increase caloric intake during pregnancy.
Choice C is incorrect because doubling caloric intake is not necessary during pregnancy.
Choice D is incorrect because while it is important to watch caloric intake during pregnancy, it is also important to increase caloric intake by approximately 300 extra calories per day.
Correct Answer is D
Explanation
Difficulty climbing stairs is an early sign of muscular dystrophy.
This is because the condition causes progressive muscle weakness, which can make it difficult for the child to perform physical activities that require muscle strength.
Choice A is not the best answer because high fevers and tiredness are not specific to muscular dystrophy and can be caused by many other conditions.
Choice B is not the best answer because muscular dystrophy causes muscle weakness, not increased muscle strength.
Choice C is not the best answer because respiratory infections and obesity are not specific to muscular dystrophy and can be caused by many other conditions.
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