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
28 to 40 pounds (13 to 18 kilograms).
Women with a low BMI (under 18.5) should gain between 28 to 40 pounds (13 to 18 kilograms) throughout their pregnancy.
Choice A, 15 to 25 pounds (7 to 11 kilograms), is incorrect because it is the recommended weight gain for women who are overweight before pregnancy.
Choice C, 16 to 30 pounds (7.25 to 14 kilograms), is incorrect because it does not fall within the recommended weight gain range for women with a low BMI.
Choice D, 25 to 35 pounds (11 to 16 kilograms), is incorrect because it is the recommended weight gain for women who are at a healthy weight before pregnancy.
Correct Answer is B
Explanation
“6 weeks after fertilization.” Teratogens can begin affecting the developing embryo as early as 10 to 14 days after conception 1.
During embryonic development, there are periods when the developing organ systems show more sensitivity to teratogens.
Choice A is incorrect because 18 weeks after fertilization is not the earliest stage of pregnancy when exposure to a teratogenic agent could occur.
Choice C is incorrect because 12 weeks after fertilization is not the earliest stage of pregnancy when exposure to a teratogenic agent could occur.
Choice D is incorrect because this is not an incomplete question/stem.
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