A nurse is caring for a client who is 1 hr 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?.
Notify the client's provider.
Increase the frequency of fundal massage.
Document the findings and continue to monitor the client.
Encourage the client to empty her bladder.
The Correct Answer is C
The correct answer is choice C.
Choice A rationale:
Notifying the provider is not necessary in this case as the findings are normal for a client who is 1 hour postpartum.
Choice B rationale:
Increasing the frequency of fundal massage is not necessary as the fundus is firm and at the umbilicus.
Choice C rationale:
The findings are normal for a client who is 1 hour postpartum. The nurse should document the findings and continue to monitor the client. Therefore, this choice is correct.
Choice D rationale:
Encouraging the client to empty her bladder is not necessary in this case as the fundus is midline.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choice D.
Choice A rationale:
This statement describes the second stage of labor, not the third. The second stage begins with full cervical dilation and ends with the delivery of the fetus.
Choice B rationale:
The third stage of labor does not end 48 hours after the delivery of the placenta. This choice is incorrect.
Choice C rationale:
While it’s important to ensure no placental fragments remain, the third stage of labor technically ends with the delivery of the placenta, not at this later point.
Choice D rationale:
This is the correct definition of the third stage of labor. It begins with the delivery of the fetus and ends with the delivery of the placenta.
Correct Answer is C
Explanation
The correct answer is choice C.
Choice A rationale:
A 1-minute Apgar score of 5 points does not necessarily indicate a congenital heart defect or an immature respiratory system.
Choice B rationale:
An Apgar score of 5 points at 1 minute does not require immediate and aggressive interventions for survival.
Choice C rationale:
A 1-minute Apgar score of 5 points indicates that the infant is experiencing moderate difficulty in adjusting to extrauterine life.
Choice D rationale:
An Apgar score of 5 points at 1 minute does not indicate that the infant is adjusting well to extrauterine life.
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