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?

Increase the rate of IV fluids.

Assist the client to ambulate.

Perform fundal massage.

Check for blood under the client's buttock.

Answer and Explanation

The Correct Answer is D

Check for blood under the client's buttock. This is because lochia rubra is the normal vaginal discharge that occurs after childbirth, consisting of blood, mucus, and tissue from the placenta and the uterus lining. It is usually heavy for the first three to four days and can pool under the client's buttocks if they are lying down. Checking for blood under the buttock can help assess the amount of bleeding and prevent complications such as infection or hemorrhage.

The other choices are not correct for the following reasons:

A. Increasing the rate of the IV fluids is not necessary because the client's fundus is firm and midline, indicating that the uterus is contracting well and preventing excessive bleeding.

B. Assisting the client to ambulate is not advisable because it can increase the lochia flow and cause fainting or dizziness due to blood loss.

C. Performing fundal massage is not indicated because the fundus is already firm and midline, meaning that the uterus is adequately contracted. Massaging a firm fundus can cause pain and discomfort to the client.

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Correct Answer is D

Explanation

This is because lochia rubra is the first stage of lochia, the vaginal discharge after giving birth. It comprises blood, shreds of fetal membranes, decidua, vernix caseosa, lanugo, and membranes. It is red in color because of the large amount of blood it contains. It lasts 1 to 4 days after birth.

Choice A is not correct because lochia alba is the last stage of lochia. It is whitish or yellowish-white in color and contains fewer red blood cells and more leukocytes, epithelial cells, cholesterol, fat, mucus, and microorganisms. It lasts from the second through the third to sixth weeks after delivery.

Choice B is not correct because there is no such thing as lochia normal. Lochia has three stages: lochia rubra, lochia serosa and lochia alba.

Choice C is not correct because lochia serosa is the second stage of lochia. It is brownish or pink in color and contains serous exudate, erythrocytes, leukocytes, cervical mucus, and microorganisms. It lasts for 4 to 12 days after delivery.

A. Administer oxytocin. B. Observe for pooling of blood under the buttocks. C. Check the client's blood pressure. D. Massage the client's fundus.

Correct Answer is D

Explanation

Massage the client’s fundus. This is because the most common cause of postpartum hemorrhage is uterine atony, which is the failure of the uterus to contract after delivery. Massaging the fundus can stimulate uterine contractions and reduce bleeding by compressing the blood vessels at the placental site.

Choice A is not correct because administering oxytocin is not the first action to take. Oxytocin is a medication that can also help the uterus contract, but it should be given after assessing the uterine tone and bleeding.

Choice B is not correct because observing for pooling of blood under the buttocks is not a priority action. It can help estimate the amount of blood loss, but it does not address the cause of bleeding or stop it.

Choice C is not correct because checking the client’s blood pressure is not the first action to take. Blood pressure can indicate hypovolemia due to blood loss, but it is not a sensitive indicator and may remain normal until a significant amount of blood is lost.

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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?

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Naxlex Comprehensive Predictor Exams

The nurse assesses a postpartum woman's perineum and notices that her lochial discharge is moderate in amount and red. The nurse would record this as what type of lochia?

Correct Answer is D

Explanation

A nurse is caring for a postpartum client who saturates a perineal pad in 10 minutes. Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

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