A nurse is collecting data from a postpartum client and finds a large amount of lochia rubra with several clots on the client's perineal pad. Which of the following actions should the nurse take first?
Request the provider perform a vaginal examination.
Check the client's fundus.
Measure the client's vital signs.
Feel for a full bladder.
The Correct Answer is B
Check the client's fundus. Lochia rubra is the normal vaginal bleeding and discharge that occurs after childbirth. It consists of blood, mucus, and tissue from the placenta and the uterus lining. It is usually bright red and may have some clots, but these clots should not be big or difficult to pass. If the client has a large amount of lochia rubra with several clots, it may indicate that the uterus is not contracting well and needs to be massaged to expel any retained tissue or blood. Checking the client's fundus is the first action the nurse should take to assess the uterine tone and location.
Choice A is incorrect because requesting the provider perform a vaginal examination is not the first action the nurse should take. A vaginal examination may be necessary if the fundal massage does not reduce the bleeding or if there is a suspicion of lacerations or hematoma, but it is not a priority intervention.
Choice C is incorrect because measuring the client's vital signs is not the first action the nurse should take. Vital signs can help monitor the client's hemodynamic status and identify signs of shock, such as tachycardia, hypotension, and pallor, but they are not as important as checking the fundus in this situation.
Choice D is incorrect because feeling for a full bladder is not the first action the nurse should take. A full bladder can displace the uterus and interfere with its contraction, leading to increased bleeding. However, it is not as likely as uterine atony to cause a large amount of lochia rubra with several clots.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Sudden infant death syndrome (SIDS) is the sudden and unexplained death of an infant under one year of age. SIDS is more likely to occur when infants sleep on their stomachs or sides, or when they are propped up with pillows or other soft bedding. These positions can interfere with the infant's breathing and increase the risk of suffocation or overheating .
Choice A is incorrect because gastroesophageal reflux (GER) is a common condition in infants that causes them to spit up frequently after feeding. GER does not increase the risk of SIDS and can be managed by feeding smaller amounts, burping the infant often, and keeping them upright for a while after feeding.
Choice C is incorrect because apnea episodes are brief pauses in breathing that occur normally in infants, especially during sleep. Apnea episodes do not increase the risk of SIDS and usually resolve by six months of age.
Choice D is incorrect because sleeping for short intervals is normal for newborns, who need to feed frequently during the day and night. Sleeping for short intervals does not increase the risk of SIDS and will gradually change as the infant grows older.
Correct Answer is C
Explanation
Fever. This is because fever is a sign of infection, which is a common and potentially serious postpartum complication. Infection can affect various parts of the body, such as the uterus (endometritis), the bladder (cystitis), the breast (mastitis), the wound (wound infection), or the blood (sepsis). Infection can cause symptoms such as fever, chills, pain, foul-smelling discharge, redness, swelling, or warmth at the site of infection.
Choice A is not correct because the change in lochia from red to white is not a sign of postpartum complication. Lochia is the vaginal discharge that occurs after childbirth. It changes color and amount over time, from red to pink to brown to yellow to white. This is a normal process of healing and does not indicate a problem unless the lochia is foul-smelling, heavy, or contains large clots³.
Choice B is not correct because fatigue and irritability are not signs of postpartum complications. Fatigue and irritability are common feelings after childbirth due to hormonal changes, sleep deprivation, physical recovery, and emotional adjustment. They do not necessarily indicate a problem unless they are severe or persistent and interfere with daily functioning or bonding with the baby.
Choice D is not correct because contractions are not signs of postpartum complication. Contractions are normal after childbirth and help the uterus shrink back to its pre-pregnancy size. They are usually mild and subside within a few days. They may be more intense during breastfeeding due to the release of oxytocin, which stimulates uterine contractions.
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