A nurse is collecting data from a client who is 14 hr postpartum.
The nurse notes: breasts soft; fundus firm, slightly deviated to the right; moderate lochia rubra; temperature 37.7° C (100° F); pulse rate 88/min; respiratory rate 18/min.
Which of the following actions should the nurse perform?
Report the client's temperature elevation.
Encourage the client to nurse more frequently so her milk will come in.
Ask the client to empty her bladder.
Increase IV fluids.
The Correct Answer is C
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The initial lochia post-delivery is known as lochia rubra.
Lochia is the vaginal discharge that occurs after childbirth and consists of blood, mucus, uterine tissue, and other materials from the uterus.
There are three stages of lochia: lochia rubra, lochia serosa, and lochia alba.
Lochia rubra is dark or bright red in color and lasts for about three to four days after delivery.
Choice B is not an answer because Fontanalis is not a term related to lochia.
Choice C is not an answer because lochia serosa is the second stage of lochia and occurs after lochia rubra.
Choice D is not an answer because lochia alba is the last stage of lochia and occurs after lochia serosa.
Correct Answer is A
Explanation
“Spiral.” A spiral fracture is a type of fracture that is frequently associated with child abuse.
Choice B is incorrect because bowing fractures are not specifically associated with child abuse.
Choice C is incorrect because closed fractures are not specifically associated with child abuse.
Choice D is incorrect because greenstick fractures are not specifically associated with child abuse.
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