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?
Document the findings and continue to monitor the client.
Encourage the client to empty her bladder.
Increase the frequency of fundal massage.
Notify the client’s provider.
The Correct Answer is A
A. The presence of lochia rubra with small clots in the immediate postpartum period is expected. The firm and midline fundus indicates appropriate uterine contraction. Continued monitoring is appropriate.
B. Encouraging the client to empty her bladder is a valid intervention, but it is not the priority in this situation.
C. Increasing the frequency of fundal massage is unnecessary, as the fundus is already firm.
D. Notifying the provider is not necessary based on the described findings, as they are within the expected range.
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Related Questions
Correct Answer is B
Explanation
A. Keeping the baby's bassinet away from fans and air conditioning is a correct practice to prevent chilling.
B. Checking the baby's temperature rectally every hour is not a standard practice and may lead to unnecessary discomfort for the baby.
C. Keeping the baby's head covered is generally recommended for warmth.
D. Keeping the infant swaddled in a warm blanket is a good practice for maintaining warmth.
Correct Answer is A
Explanation
A. Vitamin K is a fat-soluble vitamin that is essential for blood clotting. Newborns have low levels of vitamin K because they do not have the intestinal bacteria that produce it. Therefore, they are given an injection of vitamin K shortly after birth to prevent bleeding disorders.
B. Vitamin K is not crucial for the breakdown of bilirubin.
C. Vitamin K primarily plays a role in blood clotting, not the production of white blood cells.
D. Vitamin K is not directly involved in the production of red blood cells.
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