A nurse is caring for a client who is 1 hour postpartum and observes a large amount of lochia rubra and several small clots on the client's perineal pad. The fundus is midline and firm at the umbilicus. Which of the following actions should the nurse take?
Document the findings and continue to monitor the client.
Increase the frequency of fundal massage.
Encourage the client to empty her bladder.
Notify the client's provider.
The Correct Answer is A
A. The findings described are within the expected range for 1 hour postpartum, as lochia rubra and small clots are normal during the early postpartum period. The firm, midline fundus suggests adequate uterine contraction. Documenting the findings and continuing to monitor the client's progress are appropriate.
B. Increasing the frequency of fundal massage is not necessary as the fundus is already firm and midline.
C. Encouraging the client to empty her bladder is important for uterine involution, but it is not the priority in this scenario, as the fundus is already firm and midline.
D. Notifying the client's provider is not necessary at this time, as the findings are within the expected range for the early postpartum period and do not indicate any immediate complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Assessing for respiratory distress is the priority following a cesarean delivery as newborns born via cesarean section are at increased risk for respiratory complications due to potential fluid in the lungs (transient tachypnea of the newborn) or immaturity of lung function.
B. Accidental lacerations are important to assess but are not the priority immediately following a scheduled cesarean delivery.
C. Hypothermia is a concern, but assessing for respiratory distress takes precedence as it can be life-threatening if not promptly addressed.
Correct Answer is B
Explanation
A. Initiating early feeding helps promote the passage of meconium, which contains bilirubin, out of the newborn's body, reducing the risk of jaundice.
B. Preparing for an exchange blood transfusion is not appropriate for preventing jaundice at this stage. Exchange transfusion is a treatment option for severe hyperbilirubinemia that has not
responded to other measures.
C. Suctioning excess mucus with a bulb syringe is important for maintaining a patent airway in the newborn but does not directly prevent jaundice.
D. Beginning phototherapy is a treatment for jaundice once it has occurred but is not a preventive measure.
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