Question 48.

A client who has undergone a cesarean section is experiencing abdominal pain and tenderness.

Which of the following should the nurse assess for?

The correct answer is choice E) Temperature greater than 38°C for more than 48 hours.This is because a fever higher than 38°C that lasts for more than two days can indicate a postpartum infection, which is a potentially serious complication that requires immediate medical attention.A postpartum infection can affect various parts of the body, such as the uterus, the breast, or the urinary tract.

Choice A) Lochia with clots is wrong because lochia is the normal vaginal discharge that occurs after childbirth and may contain some blood clots.However, if the lochia is foul-smelling, excessive, or bright red, it may be a sign of infection.

Choice B) Fundus firmness is wrong because a firm fundus (the top of the uterus) indicates that the uterus is contracting well and preventing excessive bleeding.A soft or boggy fundus can be a sign of infection or hemorrhage.

Choice C) Abdominal distension is wrong because some abdominal swelling is normal after delivery and may take several weeks to subside.However, if the abdomen is very tender, painful, or hard, it may be a sign of infection or other complications.

Choice D) Breast tenderness is wrong because some

The correct answer is choice C) Administer oxytocin (Pitocin).Oxytocin is a hormone that stimulates uterine contractions and helps reduce postpartum bleeding by closing off the blood vessels that were attached to the placenta.

The nurse should administer oxytocin as ordered by the provider to help the client’s uterus contract and prevent hemorrhage.

Choice A) Document findings as normal is wrong because moderate bleeding with bright red blood and small clots is not normal for lochia flow 2 days after delivery.Lochia is the vaginal discharge that occurs after birth and consists of blood, tissue, mucus and bacteria.Lochia should be dark or bright red for the first 3 to 4 days, but the flow should be light and there should be no clots.Moderate bleeding with bright red blood and small clots indicates that the client may have retained placental fragments or uterine atony.

Choice B) Massage fundus until it becomes firm is wrong because the fundus is already firm, midline and at the level of the umbilicus, which indicates that the uterus is contracted properly.Massaging the fundus when it is already firm can cause more bleeding and pain.

Choice D) Increase IV fluid rate is wrong because increasing IV fluid rate will not stop the bleeding or address the underlying cause.Increasing IV fluid rate may also cause fluid overload or dilutional coagulopathy.The nurse should monitor the client’s vital signs, urine output and hematocrit levels to assess for signs of hypovolemia or anemia due to blood loss.