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 ["A","C","D","E"]
Explanation
The correct answer is choice A, C, D and E. These are the instructions that the nurse should include in the teaching for a client who had a vaginal delivery with a midline episiotomy.
• Choice A is correct because using a sitz bath three times per day and after each bowel movement can help reduce pain, swelling and infection of the perineum.
• Choice C is correct because applying ice packs to the perineum for the first 24 hours can help reduce inflammation and bleeding.
• Choice D is correct because performing Kegel exercises several times per day can help strengthen the pelvic floor muscles and improve urinary continence.
• Choice E is correct because reporting any increase in redness, swelling or discharge from the episiotomy site can help detect signs of infection or wound breakdown.
• Choice B is wrong because wiping from back to front after voiding or having a bowel movement can increase the risk of infection by introducing bacteria from the anal area to the vaginal area.The correct way to wipe is from front to back.
Correct Answer is B
Explanation
The correct answer is choice B. Palpate fundus.The nurse should first assess the tone of the uterus by palpating the fundus, as uterine atony is the most common cause of postpartum hemorrhage.
If the uterus is boggy or soft, the nurse should massage it gently until it becomes firm and contracts.
This will help control the bleeding from the placental site.
Choice A is wrong because assessing vital signs is not the first priority in this situation.Vital signs may not reflect the severity of blood loss until late in the process of hemorrhage.
The nurse should monitor vital signs after ensuring that the uterus is contracted.
Choice C is wrong because administering oxytocin as prescribed is not the first action the nurse should take.
Oxytocin is a medication that stimulates uterine contractions and reduces bleeding, but it should be given
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