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 C
Explanation
Choice A rationale
Alcohol swabs are not recommended for cleaning the circumcision site as they may irritate the delicate tissue and delay healing. Proper care involves gentle cleansing with water and avoiding substances that can cause discomfort or tissue damage.
Choice B rationale
While monitoring for bleeding is essential, small spots of blood on the diaper may be normal. Excessive bleeding, however, is a cause for concern and should prompt immediate medical consultation, emphasizing the need to differentiate normal healing signs from complications.
Choice C rationale
A loose diaper reduces pressure on the circumcision site and prevents friction, which could cause pain or disrupt the healing process. This practice ensures the Plastibell stays in position until it detaches naturally, minimizing discomfort and promoting tissue recovery.
Choice D rationale
The Plastibell typically falls off within 5 to 8 days, not within 24 hours. Misunderstanding this timeframe can cause undue anxiety for parents or lead to premature removal attempts, which may complicate the healing process or cause injury to the site.
Correct Answer is D
Explanation
Choice A rationale
Frequent cervical assessments increase the risk of introducing pathogens into the reproductive tract, especially with premature rupture of membranes (PROM). Continuous assessments are unnecessary unless labor is progressing or there are indications of infection. PROM exposes the fetus to potential infections like chorioamnionitis, and invasive procedures should be minimized to reduce infection risk.
Choice B rationale
Preparing for delivery is not a priority intervention unless signs of labor or fetal distress occur. At 32 weeks, preterm delivery poses significant risks, including respiratory distress syndrome and intraventricular hemorrhage. The goal is to prolong pregnancy to improve neonatal outcomes while closely monitoring the client for complications. Immediate delivery is reserved for emergent situations.
Choice C rationale
Providing emotional support is essential but does not directly address the risk of infection associated with PROM. While psychological support is beneficial, it is secondary to interventions aimed at preventing infection, which is the primary concern. Emotional well-being should complement, not replace, medical interventions.
Choice D rationale
Administering parenteral antibiotics helps prevent infection in cases of PROM, particularly when membranes rupture prematurely and expose the fetus to pathogens. Early antibiotic treatment reduces the risk of ascending infections like chorioamnionitis and neonatal sepsis. This intervention is crucial to protect maternal and fetal health during prolonged PROM.
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