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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Petechiae and bleeding around the IV access site are not typically associated with preeclampsia.
B. Disseminated intravascular coagulation (DIC) is a potential complication of abruptio placentae, characterized by widespread activation of the clotting cascade followed by consumption of clotting factors, leading to bleeding and microvascular thrombosis.

C. Puerperal infection is a risk following childbirth but is not specifically associated with petechiae and bleeding around the IV access site.
D. Anaphylactoid syndrome of pregnancy is a rare complication characterized by sudden hypotension, bronchospasm, and vascular collapse, which is not typically associated with petechiae and bleeding around the IV access site.

A. Ventrogluteal B. Vastus lateralis C. Dorso-gluteal D. Deltoid

Correct Answer is B

Explanation

A. The ventrogluteal site can be used for IM injections in older infants but is not typically used in newborns.
B. The vastus lateralis muscle is the preferred site for IM injections in newborns due to its size and accessibility.
C. The dorso-gluteal site is not recommended for IM injections in infants due to the risk of injury to the sciatic nerve.
D. The deltoid muscle is not typically used for IM injections in newborns due to its small size and less developed musculature.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

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Correct Answer is B

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