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
While excessive fatigue and headache can occur in pregnancy, they are not typically signs of labor.
Choice B rationale
A sudden gush of clear fluid from the vagina, also known as rupture of membranes, is a sign that labor may be starting.
Choice C rationale
Sharp, right-sided abdominal pain is not a typical sign of labor. It could indicate other issues such as appendicitis.
Choice D rationale
An increased pulse rate and upper abdominal pain are not typical signs of labor.
Correct Answer is C
Explanation
Choice A rationale
Assisting with amnioinfusion is not the first priority. Amnioinfusion is a procedure where a sterile solution is introduced into the uterus to increase the volume of fluid around the fetus. It is typically used in cases of oligohydramnios (low amniotic fluid) or to dilute thick meconium in the amniotic fluid.
Choice B rationale
Inserting a scalp electrode is not the first priority. A scalp electrode is a device used to monitor the fetal heart rate more accurately. It is usually used when external monitoring does not provide a clear reading or when there is a need for continuous detailed monitoring.
Choice C rationale
Changing the woman’s position is the correct action. Late decelerations in the fetal heart rate can be a sign of uteroplacental insufficiency, a condition where the placenta cannot deliver adequate oxygen to the fetus. Changing the woman’s position can improve placental blood flow and potentially improve the oxygen supply to the fetus.
Choice D rationale
Notifying the health care provider is important but not the first priority. The nurse should first attempt interventions such as changing the woman’s position to improve the fetal heart rate.
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