A nurse is assessing a client who delivered an infant vaginally 2 days ago and notes that the fundus is firm, midline, and at the level of the umbilicus, lochia rubra is moderate, and there are no clots present in the lochia flow.
Which of the following actions should the nurse take?
Document findings as normal
Massage fundus until it becomes firm
Administer oxytocin
Increase IV fluid rate
The Correct Answer is A
The correct answer is choice A) Document findings as normal.
The fundus is the upper part of the uterus that contracts after delivery to prevent bleeding. The fundus should be firm, midline, and at the level of the umbilicus or lower on the second postpartum day. Lochia rubra is the normal bloody discharge that occurs for the first few days after delivery and should not contain large clots. The normal range of lochia rubra is scant to moderate.
Choice B) Massage fundus until it becomes firm is wrong because the fundus is already firm and does not need further stimulation.
Choice C) Administer oxytocin (Pitocin) is wrong because oxytocin is a medication that helps the uterus contract and is not indicated for a firm fundus.
Choice D) Increase IV fluid rate is wrong because IV fluids are not related to the assessment of the fundus and lochia and may cause fluid overload.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is E
Explanation
The correct answer is choice E) Temperature greater than 38°C for more than 48 hours.This is because a fever higher than 38°C that lasts for more than two days can indicate a postpartum infection, which is a potentially serious complication that requires immediate medical attention.A postpartum infection can affect various parts of the body, such as the uterus, the breast, or the urinary tract.
Choice A) Lochia with clots is wrong because lochia is the normal vaginal discharge that occurs after childbirth and may contain some blood clots.However, if the lochia is foul-smelling, excessive, or bright red, it may be a sign of infection.
Choice B) Fundus firmness is wrong because a firm fundus (the top of the uterus) indicates that the uterus is contracting well and preventing excessive bleeding.A soft or boggy fundus can be a sign of infection or hemorrhage.
Choice C) Abdominal distension is wrong because some abdominal swelling is normal after delivery and may take several weeks to subside.However, if the abdomen is very tender, painful, or hard, it may be a sign of infection or other complications.
Choice D) Breast tenderness is wrong because some
Correct Answer is A
Explanation
The correct answer is choice A. Increased clotting factors.Increased clotting factors are a physiological adaptation to pregnancy that reduces the risk of hemorrhage during delivery, but also increases the risk of venous thromboembolism (VTE) in pregnancy and postpartum.The risk of VTE is highest in the first week after delivery and gradually declines over the next 12 weeks.
Choice B is wrong because decreased blood volume is not a risk factor for VTE.In fact, blood volume increases by about 50% during pregnancy to meet the increased metabolic demands of the mother and fetus.
Choice C is wrong because increased cardiac output is not a risk factor for VTE.
Cardiac output also
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.