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 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.
Correct Answer is D
Explanation
A postpartum fever is defined as a temperature greater than 100.4 degrees F (38.0 degrees C) on at least two occasions.
These fevers cannot be ignored as they can represent serious infections. The first task is to identify the source.
Choice A is not correct because continuing to monitor for another hour may delay necessary treatment.
Choice B is not correct because administering an antipyretic may only treat the symptom and not address the underlying cause of the fever.
Choice C is not correct because assisting the client in ambulation does not address the underlying cause of the fever.
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