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?
Notify the client’s provider.
Document the findings and continue to monitor the client.
Increase the frequency of fundal massage.
Encourage the client to empty her bladder.
The Correct Answer is B
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Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
An Apgar score of 7 is considered fairly low and would typically be associated with a newborn who has more significant health concerns.
Choice B rationale
An Apgar score of 8 is considered to be within the normal range. This score would be consistent with a newborn who has a pink trunk and head, bluish hands and feet, flexed extremities, a weak and slow cry, a heart rate of 130/min, and cries in response to suctioning.
Choice C rationale
An Apgar score of 9 is considered to be within the normal range. However, given the newborn’s weak and slow cry, an Apgar score of 9 would be less likely.
Choice D rationale
An Apgar score of 10 is very unusual, as almost all newborns lose 1 point for blue hands and feet, which is normal for after birth.
Correct Answer is B
Explanation
Choice A rationale
Administering oxytocin infusion is usually done to stimulate uterine contractions and prevent postpartum hemorrhage. However, it’s not the first action to take when the client’s blood pressure is low.
Choice B rationale
Evaluating the firmness of the uterus is crucial in this situation. A soft or “boggy” uterus could indicate uterine atony, a condition that can lead to serious postpartum hemorrhage. This could be the cause of the client’s low blood pressure.
Choice C rationale
Initiating oxygen therapy by non-rebreather mask can help increase the client’s oxygen saturation levels, but it doesn’t address the underlying cause of the low blood pressure.
Choice D rationale
Obtaining a type and crossmatch is important if the client needs a blood transfusion. However, it’s not the first action to take. The nurse should first assess for possible causes of the low blood pressure.
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