A nurse is assessing a client 1 hour after delivery and notices a large amount of lochia rubra along with several small clots on the perineal pad.
The client's fundus is firm and located at the umbilical level, in the midline.
What action should the nurse take next?
Increase the frequency of fundal massage.
Document the findings and continue to monitor the client.
Notify the provider immediately.
Encourage the client to empty her bladder.
The Correct Answer is B
Choice A rationale
Increasing fundal massage frequency is not necessary when the fundus is already firm and midline. Fundal massage is primarily used to address uterine atony, which is absent in this scenario. The findings indicate normal post-delivery uterine tone rather than a complication.
Choice B rationale
Documenting the findings and monitoring the client is appropriate when the fundus is firm and midline. The presence of small clots and a large amount of lochia rubra can be normal within the first hour postpartum. Continued observation ensures any potential issues are identified early.
Choice C rationale
Immediate notification of the provider is unnecessary unless there are signs of abnormal bleeding, uterine atony, or other complications. Since the fundus is firm and midline, this suggests the uterine tone is adequate, and intervention is not urgently needed.
Choice D rationale
Encouraging the client to empty her bladder is not relevant here, as the fundus is located appropriately at the midline and umbilical level, indicating that bladder distention is not affecting uterine position. This action would not address the described findings.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D"]
Explanation
Choice A rationale
Accurate measurement of intake and output is crucial after atrial septal defect repair to detect potential fluid imbalances or kidney dysfunction. Monitoring ensures early intervention in cases of dehydration or fluid overload.
Choice B rationale
Providing uninterrupted rest promotes recovery by minimizing stress on the cardiovascular system and reducing metabolic demands post-surgery. Adequate rest also allows tissue healing and stabilizes vital parameters.
Choice C rationale
Maintaining a thermoneutral environment prevents temperature fluctuations, which could increase metabolic demand and stress the healing heart. Temperature regulation is particularly important in infants with compromised cardiac function.
Choice D rationale
Encouraging bonding supports emotional and psychological recovery for both the infant and parents. Physical closeness can improve the infant's developmental outcomes and reduce parental anxiety after surgery.
Choice E rationale
Using an incentive spirometer 10 times hourly is not appropriate for infants. Incentive spirometers are designed for cooperative patients, typically older children or adults, as they require active participation in deep-breathing exercises.
Correct Answer is B
Explanation
Choice A rationale
Teaching the child how to use an inhaler supports self-management but does not address developmental readiness for independent inhaler use. At five years old, children often require supervision due to incomplete cognitive and motor development.
Choice B rationale
Providing information to the caregiver about child development stages clarifies expectations for independent inhaler use. This knowledge aligns with the protective factor of ensuring developmentally appropriate interventions for pediatric asthma management.
Choice C rationale
Community resources offer support but do not directly relate to the child's ability to use the inhaler without supervision. While beneficial, this option does not prioritize the developmental readiness aspect of pediatric care.
Choice D rationale
Referring the caregiver to an asthma educator focuses on skill-building and education but overlooks the specific developmental readiness of the child. Direct caregiver education on developmental milestones is more impactful in this context. .
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.