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 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
Correct Answer is D
Explanation
The correct answer is choice D. I would stop feeding my baby until the pain goes away.This response indicates a need for further teaching because stopping breastfeeding can worsen the uterine cramping and also affect the milk supply and the baby’s nutrition.Uterine cramping or “afterpains” are normal after delivery and are caused by the uterus contracting and shrinking back to its normal size.Breastfeeding can trigger these contractions because it stimulates the release of oxytocin, a hormone that helps the uterus contract.
Choice A is wrong because ibuprofen is a safe and effective pain reliever for postpartum women and can be taken before feeding the baby.Choice B is wrong because massaging the abdomen gently during feeding can help ease the afterpains by stimulating blood flow and relaxing the muscles.Choice C is wrong because relaxation and breathing techniques can also help reduce the pain by lowering stress and tension levels.These are some of the self-help treatments that can be used along with medications to manage postpartum pain.
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.