Which of the following findings should alert a nurse assessing a client who is 8 hr postpartum and multiparous?

Fundus three fingerbreadths above the umbilicus.

Moderate lochia rubra.

Blood pressure 130/84 mm Hg.

Moderate swelling of the labia.

Answer and Explanation

The Correct Answer is A

Choice A rationale
A fundus that is three fingerbreadths above the umbilicus 8 hours postpartum is a sign of urinary retention, which can displace the uterus and inhibit uterine contraction, leading to postpartum hemorrhage.
Choice B rationale
Moderate lochia rubra, or bloody discharge, is normal within the first few days after childbirth.
Choice C rationale
A blood pressure of 130/84 mm Hg is within the normal range for a postpartum woman.
Choice D rationale
Moderate swelling of the labia can be a normal finding after a vaginal birth.

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Correct Answer is A

Explanation

Choice A rationale
When breastfeeding, it is recommended that the mother places her nipple and some of the areola into the baby’s mouth. This allows the baby to have a good latch, which is important for effective breastfeeding.
Choice B rationale
While it is important for the baby to take a good portion of the breast into their mouth, suggesting to include some breast tissue beyond the areola might be too much for a newborn’s small mouth.
Choice C rationale
This statement is not entirely accurate. While a newborn’s mouth is small, they should take as much of the nipple and areola into their mouth as possible to ensure effective breastfeeding.
Choice D rationale
While babies have certain instincts, they and their mothers often need guidance and practice to achieve a good latch and effective breastfeeding.

A. Prepare to administer oxytocic medication. B. Assist the client on a bedpan to urinate. C. Palpate the client’s uterine fundus. D. Increase the client’s fluid intake.

Correct Answer is C

Explanation

Choice A rationale
Administering oxytocic medication is an intervention that may be necessary if the client’s bleeding does not stop or if the uterus does not contract adequately. However, the priority is to assess the situation, which includes palpating the uterine fundus.
Choice B rationale
Assisting the client on a bedpan to urinate can help if the bladder is full and preventing the uterus from contracting properly. However, the priority is to assess the uterus by palpating the uterine fundus.
Choice C rationale
Palpating the client’s uterine fundus is the priority nursing intervention. A boggy uterus (one that does not contract properly) is a common cause of postpartum hemorrhage. If the uterus is not firm upon palpation, massage it until it firms up.
Choice D rationale
Increasing the client’s fluid intake can help replace lost fluids, but it is not the priority intervention. The first step is to assess the cause of the bleeding, which includes palpating the uterine fundus.

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Which of the following findings should alert a nurse assessing a client who is 8 hr postpartum and multiparous?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting a client who is postpartum with her first breastfeeding experience. When the client asks how much of the nipple she should put into the newborn’s mouth, which of the following responses should the nurse make?

Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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