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 C
Explanation
A full bladder can displace the uterus and cause it to deviate to one side.
Choice A is not correct because a temperature of 37.7° C (100° F) is within the normal range for a postpartum client.
Choice B is not correct because the client’s milk production is not related to the findings noted by the nurse.
Choice D is not correct because there is no indication that the client needs an increase in IV fluids.
Correct Answer is C
Explanation
A soft toy that squeaks or crackles when squeezed is a good choice for a 7- month-old infant.
At this age, babies love to explore using their mouths and hands, and they might start teething around 6 months old.
A soft toy that makes noise when squeezed can provide sensory stimulation and help with the development of fine motor skills.
A set of blocks to build a block tower is not suitable for a 7-month-old infant as they are still developing their motor skills.
A colorful crib mobile that plays music is more suitable for younger infants.
A wooden farm animal puzzle with large pieces is not suitable for a 7-month-old infant as they are still developing their cognitive and motor skills.
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