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
Radiographs are vital to the diagnosis of Legg-Calve-Perthes disease.
Initial X-rays might look normal because it can take one to two months after symptoms begin for the changes associated with Legg-Calve-Perthes disease to become evident on X-rays.
The doctor will likely recommend several X-rays over time, to track the progression of the disease.
Bone biopsy is not a diagnostic procedure for Legg-Calve-Perthes disease.
MRI can visualize bone damage caused by Legg-Calve-Perthes disease more clearly than X-rays can but are not always necessary.
Genetic testing is not a diagnostic procedure for Legg-Calve-Perthes disease.
Correct Answer is C
Explanation
This is an antibiotic ointment that is applied to the eyes of newborns to prevent ophthalmia neonatorum, a serious eye infection caused by gonorrhea.
Ophthalmia neonatorum can cause blindness if left untreated and can occur even if the mother does not have symptoms of gonorrhea.
Erythromycin is the only drug approved by the FDA for this purpose and is mandated in most states.
Choice A.
Nystatin is incorrect, as this is an antifungal medication that is used to treat oral thrush or diaper rash in newborns, not eye infections.
Choice B.
Ceftriaxone is incorrect, as this is an antibiotic injection that is used to treat systemic gonorrhea infections in adults or newborns, not eye infections.
Choice D.
Ofloxacin is incorrect, as this is an antibiotic eye drop that is used to treat bacterial conjunctivitis in older children and adults, not ophthalmia neonatorum in newborns.
Therefore, choice C is the best answer to this question.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today