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 B
Explanation
A. Lateral incisors are present:At 6 months, infants typically begin teething, but the lateral incisors usually do not appear until around 9 to 13 months. The first teeth to emerge are usually the lower central incisors.
B. Posterior fontanel is closed:The posterior fontanel, or the soft spot at the back of the baby's head, typically closes by 2 to 3 months of age. Therefore, it is expected to be closed by the time the infant is 6 months old.
C. Infant's birth weight is tripled:By 6 months, infants generally double their birth weight. Tripling of birth weight is more commonly expected by the end of the first year.
D. Infant sits well without support:Most infants begin to sit without support around 7 to 9 months. At 6 months, they may sit with some support but are not yet expected to sit well independently.
Correct Answer is A
Explanation
“Spiral.” A spiral fracture is a type of fracture that is frequently associated with child abuse.
Choice B is incorrect because bowing fractures are not specifically associated with child abuse.
Choice C is incorrect because closed fractures are not specifically associated with child abuse.
Choice D is incorrect because greenstick fractures are not specifically associated with child abuse.
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