A nurse is caring for a client who delivered an infant vaginally 2 days ago and notes that there are no clots present in the lochia flow, but there is moderate bleeding with bright red blood and small clots present when massaging the fundus which is firm, midline, and at the level of the umbilicus.

Document findings as normal

Massage fundus until it becomes firm

Administer oxytocin

Increase IV fluid rate

Answer and Explanation

The Correct Answer is C

The correct answer is choice C) Administer oxytocin (Pitocin). Oxytocin is a hormone that stimulates uterine contractions and helps reduce postpartum bleeding by closing off the blood vessels that were attached to the placenta.

The nurse should administer oxytocin as ordered by the provider to help the client’s uterus contract and prevent hemorrhage.

Choice A) Document findings as normal is wrong because moderate bleeding with bright red blood and small clots is not normal for lochia flow 2 days after delivery. Lochia is the vaginal discharge that occurs after birth and consists of blood, tissue, mucus and bacteria. Lochia should be dark or bright red for the first 3 to 4 days, but the flow should be light and there should be no clots. Moderate bleeding with bright red blood and small clots indicates that the client may have retained placental fragments or uterine atony.

Choice B) Massage fundus until it becomes firm is wrong because the fundus is already firm, midline and at the level of the umbilicus, which indicates that the uterus is contracted properly. Massaging the fundus when it is already firm can cause more bleeding and pain.

Choice D) Increase IV fluid rate is wrong because increasing IV fluid rate will not stop the bleeding or address the underlying cause. Increasing IV fluid rate may also cause fluid overload or dilutional coagulopathy. The nurse should monitor the client’s vital signs, urine output and hematocrit levels to assess for signs of hypovolemia or anemia due to blood loss.

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Correct Answer is A

Explanation

The correct answer is choice A.The woman should change her perineal pad every time she uses the bathroom to prevent infection and promote healing of the perineal area.

Some possible explanations for the other choices are:

• Choice B is wrong because the woman should wipe her perineum from front to back after urinating or defecating to avoid introducing bacteria from the anus to the vagina or urethra.

• Choice C is wrong because the woman should apply ice packs on her perineum for the first 24 hours after birth, not for the first week.

Ice packs help reduce swelling and pain in the per

A. Nausea and vomiting. B. Increased appetite. C. Increased urine output D. Decreased heart rate.

Correct Answer is A

Explanation

The correct answer is choice A) Nausea and vomiting.This is because nausea and vomiting are common adverse effects of many antibiotics, especially clindamycin and gentamicin, which are often used to treat postpartum endometritis.Nausea and vomiting can also indicate a more serious complication of antibiotic therapy, such as Clostridioides difficile infection.

Choice B) Increased appetite is wrong because antibiotics do not typically affect appetite, and postpartum endometritis may cause loss of appetite due to fever, pain, and inflammation.

Choice C) Increased urine output is wrong because antibiotics do not usually increase urine output, and postpartum endometritis may cause dehydration due to fever and vomiting.

Choice D) Decreased heart rate is wrong because antibiotics do not generally lower heart rate, and postpartum endometritis may cause tachycardia due to fever, infection, and sepsis.

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A nurse is caring for a client who delivered an infant vaginally 2 days ago and notes that there are no clots present in the lochia flow, but there is moderate bleeding with bright red blood and small clots present when massaging the fundus which is firm, midline, and at the level of the umbilicus.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing a discharge plan for a postpartum woman who had a vaginal delivery with a second-degree perineal tear. The nurse includes instructions on how to care for the perineum at home. Which statement by the woman indicates that she understands the instructions?

Correct Answer is A

Explanation

A nurse is caring for a client who has postpartum endometritis and is receiving IV antibiotics. Which of the following findings indicates that the client is experiencing an adverse effect of the medication?

Correct Answer is A

Explanation

Question 48. A client who has undergone a cesarean section is experiencing abdominal pain and tenderness. Which of the following should the nurse assess for?

A nurse is caring for a postpartum client who has an episiotomy wound infection. Which of the following should the nurse do? (Select all that apply.) A) Administer antibiotics as prescribed.

A nurse is caring for a postpartum client who reports heavy vaginal bleeding and passing large clots since delivery 2 days ago. Which of the following actions should the nurse take first?

A nurse is evaluating a postpartum woman’s knowledge about pain management after birth. The nurse asks the woman what she would do if she has uterine cramping while breastfeeding her baby. Which response by the woman indicates a need for further teaching?

(Select all that apply) A nurse is monitoring a postpartum woman who is taking codeine for severe pain after birth. The nurse knows that codeine can pass through breastmilk and cause adverse effects in the baby. Which signs and symptoms should the nurse watch for in the baby?

A nurse is assessing a postpartum client for signs of infection. Which of the following should the nurse report immediately? A) Lochia with clots.

(from search results) What factor places the postpartum client at risk for thromboembolism?

A nurse is caring for a client who received meperidine (Demerol) IV for pain relief during labor 2 hours ago and is now ready to deliver vaginally. Which of the following medications should the nurse have available to reverse respiratory depression in the newborn?