A nurse is collecting data from a client who delivered 2 hours ago. The client has moderate lochia rubra, temperature within normal limits, breasts soft, fundus firm, slightly deviated to the right, pulse rate 88/min, respiratory rate 18/min.
Which of the following actions should the nurse perform?

Encourage the client to nurse more frequently so her milk will come in

Report the client's temperature elevation

Ask the client to empty her bladder

Increase IV fluids

Answer and Explanation

The Correct Answer is C

ask the client to empty her bladder. A full bladder can cause the uterus to be displaced and lead to excessive bleeding. The moderate lochia rubra, normal temperature, soft breasts, firm fundus, slightly deviated to the right, pulse rate of 88/min, and respiratory rate of 18/min are all normal findings.

Choice A is not correct because the client's milk will come in regardless of nursing frequency.

Choice B is not correct because the client's temperature is within normal limits.

Choice D is not correct because there is no indication of an increase in IV fluids.

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Correct Answer is D

Explanation

Precipitous birth

This is because precipitous birth, which is defined as a labor that lasts less than three hours from the onset of contractions to delivery, is a risk factor for postpartum hemorrhage. This is because the uterus may not contract well after a rapid delivery, leading to uterine atony and bleeding. Other risk factors for postpartum hemorrhage include uterine overdistension, oxytocin use, placental abruption, placenta previa, infection, coagulation disorders, and previous history of postpartum hemorrhage.

Choice A is not correct because gestational hypertension is not a risk factor for postpartum hemorrhage. It is a condition that causes high blood pressure during pregnancy and can lead to complications such as preeclampsia, eclampsia, and placental abruption³.

Choice B is not correct because small for gestational age newborn is not a risk factor for postpartum hemorrhage. It is a condition that indicates that the baby's growth was restricted in the womb and weighs less than 90% of other babies of the same gestational age. It can be caused by maternal factors, placental factors, or fetal factors⁴.

Choice C is not correct because a two-vessel umbilical cord is not a risk factor for postpartum hemorrhage. It is a condition that occurs when the umbilical cord has only one artery and one vein instead of the normal two arteries and one vein. It can be associated with congenital anomalies, intrauterine growth restriction, and stillbirth.

A. Massage the fundus B. Initiate measures that encourage voiding C. Position the patient flat D. Notify the doctor

Correct Answer is A

Explanation

Massage the fundus. This is because massaging the fundus (the upper part of the uterus) can help the uterus contract and prevent excessive bleeding after delivery. A soft, boggy uterus indicates uterine atony, which is a failure of the uterus to contract sufficiently after childbirth.

Uterine atony is the most common cause of postpartum hemorrhage, which can be life-threatening if not treated promptly¹².

Choice B is not correct because initiating measures that encourage voiding is not the appropriate intervention for a soft, boggy uterus. A full bladder can interfere with uterine contractions and cause bleeding, so it is important to empty the bladder after delivery. However, this should be done after massaging the fundus.

Choice C is not correct because positioning the patient flat is not the appropriate intervention for a soft, boggy uterus. Positioning the patient flat can increase blood loss and reduce venous return. The patient should be positioned with the head slightly elevated and the legs flexed to improve blood circulation and prevent shock³.

Choice D is not correct because notifying the doctor is not the first intervention for a soft, boggy uterus. Notifying the doctor is important if bleeding persists or worsens despite massaging the fundus. The doctor may order medications or other treatments to stop the bleeding and prevent complications¹.

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A nurse is collecting data from a client who delivered 2 hours ago. The client has moderate lochia rubra, temperature within normal limits, breasts soft, fundus firm, slightly deviated to the right, pulse rate 88/min, respiratory rate 18/min. Which of the following actions should the nurse perform?

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Naxlex Comprehensive Predictor Exams

A nurse is reviewing the medical record of a client who experienced a vaginal birth 2 hr ago. The nurse should identify which of the following findings places the client at risk for a postpartum hemorrhage.

Correct Answer is D

Explanation

Following delivery, the nurse's assessment reveals a soft, boggy uterus located above the level of the umbilicus. The appropriate intervention is:

Correct Answer is A

Explanation

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A nurse is collecting data from a client who delivered 2 hours ago. The client has moderate lochia rubra, temperature within normal limits, breasts soft, fundus firm, slightly deviated to the right, pulse rate 88/min, respiratory rate 18/min.
Which of the following actions should the nurse perform?