What action should a nurse take when caring for a client who is 1 hr postpartum and observes a large amount of lochia rubra and several small clots on the client’s perineal pad, with the fundus midline and firm at the umbilicus?

Choice A rationale
The client understanding the importance of monitoring their incision for signs of infection, such as discharge, indicates effective teaching. It is crucial for the client to report any changes to their healthcare provider promptly.
Choice B rationale
Having a fever during the first week at home is not a normal postoperative symptom and could indicate an infection. Therefore, this statement does not indicate effective teaching.
Choice C rationale

Resting in a recliner until the incision is healed is not necessary. While it’s important for the client to rest and recover after surgery, they should also engage in light physical activity, such as walking, to promote circulation and prevent complications such as blood clots.
Choice D rationale
The client should not have unrelieved pain in their abdomen. Persistent pain could indicate a complication, such as an infection or a hematoma. Therefore, this statement indicates effective teaching.

Choice A rationale
The left lower quadrant is not the most likely location to auscultate fetal heart tones if the nurse palpates a round, firm, movable part in the fundus of the uterus and a long, smooth surface on the client’s right side. These findings suggest that the fetus is in a breech position with its back on the left side, which would place the fetal chest, and thus the heart tones, in the right lower quadrant.
Choice B rationale
The right upper quadrant is not the most likely location to auscultate fetal heart tones if the nurse palpates a round, firm, movable part in the fundus of the uterus and a long, smooth surface on the client’s right side. These findings suggest that the fetus is in a breech position with its back on the left side, which would place the fetal chest, and thus the heart tones, in the right lower quadrant.
Choice C rationale
The left upper quadrant is not the most likely location to auscultate fetal heart tones if the nurse palpates a round, firm, movable part in the fundus of the uterus and a long, smooth surface on the client’s right side. These findings suggest that the fetus is in a breech position with its back on the left side, which would place the fetal chest, and thus the heart tones, in the right lower quadrant.
Choice D rationale
The right lower quadrant is the most likely location to auscultate fetal heart tones if the nurse palpates a round, firm, movable part in the fundus of the uterus and a long, smooth surface on

the client’s right side. These findings suggest that the fetus is in a breech position with its back on the left side, which would place the fetal chest, and thus the heart tones, in the right lower quadrant.