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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A rationale

A history of pelvic inflammatory disease may result in complications like infertility or chronic pelvic pain but does not specifically indicate endometriosis. Endometriosis involves the ectopic implantation of endometrial tissue, unrelated to infection from PID.

Choice B rationale

An atypical Papanicolaou smear suggests cervical cell abnormalities due to infection, inflammation, or dysplasia, but it does not correlate with endometriosis, which is a distinct gynecological condition involving ectopic endometrial tissue growth.

Choice C rationale

Dysmenorrhea unresponsive to NSAIDs is a defining symptom of endometriosis. This pain results from the inflammatory response and cyclic bleeding of ectopic endometrial tissue, which can cause significant discomfort and impair quality of life.

Choice D rationale

Abdominal bloating several days before menses may be linked to hormonal fluctuations or gastrointestinal issues but is not a primary symptom of endometriosis. While some affected individuals experience bloating, it is not a diagnostic feature like severe, treatment-resistant pain. .

A. Interview the client privately. B. Maintain a calm, caring, professional demeanor. C. Ask the teen if she feels safe. D. Contact the police.

Correct Answer is ["A","B","C"]

Explanation

Choice A rationale

Interviewing the client privately ensures confidentiality and allows for honest disclosure of the situation without fear of intimidation or manipulation by accompanying individuals. This approach is critical in identifying domestic abuse victims and initiating proper interventions.

Choice B rationale

A calm, caring, and professional demeanor fosters trust and reduces the client’s anxiety or fear. It ensures the nurse-patient relationship is non-threatening, encouraging the teen to open up about her experiences and facilitating accurate assessment and care.

Choice C rationale

Assessing whether the teen feels safe helps identify her immediate risks and the presence of a potential threat. Recognizing unsafe living conditions enables the nurse to involve appropriate protective and social services to ensure the client’s safety.

Choice D rationale

Contacting the police should be done only with the client’s consent unless mandated by law. Immediate police involvement without consent may jeopardize the client’s trust in the healthcare system and compromise her willingness to seek help in the future.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A clinic nurse is assessing a client with a suspected diagnosis of endometriosis.Which of the following findings in the client's medical history should the nurse identify as consistent with a diagnosis of endometriosis?

Correct Answer is C

Explanation

A 16-year-old is brought to the emergency room by her boyfriend with bruising around her eyes and neck.When asked what happened, she states, "I walked into a door.”. What are the most appropriate interventions by the nurse?

Correct Answer is ["A","B","C"]

Explanation

The nurse is preparing a 2-year-old child with cystic fibrosis for discharge home.Which statement made by the parents suggests that additional education is necessary?

Which task is most appropriate for the nurse to delegate to the unlicensed assistive personnel on a pediatric unit?

Identify the trimester when each fetal development finding occurs. Select the appropriate trimester for each finding:

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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?