A nurse is caring for a client who is 4 hours postpartum.
The nurse finds a small amount of lochia rubra on the client's perineal pad.
The fundus is midline and firm at the umbilicus.
Which of the following actions should the nurse take?
Perform fundal massage.
Increase the rate of the IV fluids.
Assist the client to ambulate.
Check for blood under the client's buttock.
The Correct Answer is D
Choice A rationale
Performing fundal massage is indicated for a boggy or displaced fundus, which suggests uterine atony and a risk of hemorrhage. In this scenario, the fundus is described as firm and midline at the umbilicus, indicating appropriate uterine involution and contraction. Therefore, fundal massage is not necessary.
Choice B rationale
Increasing the rate of IV fluids is typically done to expand circulating blood volume in cases of hypovolemia or hemorrhage. Given the small amount of lochia rubra and a firm, midline fundus, there is no indication of excessive blood loss or hypovolemia that would warrant an increase in IV fluid rate.
Choice C rationale
Assisting the client to ambulate is generally encouraged in the postpartum period to promote circulation and prevent complications like deep vein thrombosis. However, in the context of assessing for potential concealed hemorrhage, ambulation is not the most immediate or appropriate action; the priority is to rule out hidden blood loss.
Choice D rationale
A small amount of lochia rubra with a firm, midline fundus is a normal finding. However, checking for blood under the client's buttock is crucial to rule out concealed hemorrhage, as blood can pool unnoticed beneath the client, masking significant blood loss despite a firm fundus. This ensures a comprehensive assessment of blood loss.
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Related Questions
Correct Answer is D
Explanation
Choice A rationale
This statement is incorrect as caloric needs increase during pregnancy to support fetal growth, placental development, and increased maternal metabolic demands. Inadequate caloric intake can lead to poor fetal outcomes, including low birth weight and impaired development.
Choice B rationale
While caloric needs do increase, an additional 500 calories is generally too high for the average pregnancy. The recommended increase is typically lower, focusing on nutrient-dense foods to ensure sufficient energy for both mother and fetus.
Choice C rationale
Doubling caloric intake is excessive and can lead to excessive maternal weight gain, increasing risks for gestational diabetes, preeclampsia, and delivery complications. The concept of "eating for two" is a common misconception that often leads to overconsumption.
Choice D rationale
During the second and third trimesters, the average pregnant woman requires an additional 300 calories per day above her pre-pregnancy needs. This increase provides adequate energy for rapid fetal growth, development, and maternal physiological changes, such as increased blood volume and uterine expansion.
Correct Answer is B
Explanation
Choice A rationale
A weight gain of 25 to 35 pounds is the general recommendation for women who begin pregnancy with a normal body mass index (BMI) of 18.5 to 24.9. Since the client has a BMI of 26.5, she falls into the overweight category, and her recommended weight gain range is different to optimize maternal and fetal outcomes.
Choice B rationale
For pregnant individuals who are classified as overweight, defined by a BMI of 25.0 to 29.9, the recommended total weight gain during pregnancy is 15 to 25 pounds (approximately 6.8 to 11.3 kg). This guideline aims to minimize risks such as gestational diabetes, preeclampsia, and macrosomia while ensuring adequate fetal growth.
Choice C rationale
A weight gain of 11 to 20 pounds is the recommendation for pregnant individuals who are classified as obese, with a BMI of 30.0 or greater. This client's BMI of 26.5 places her in the overweight category, not obese, necessitating a different target range for gestational weight gain to promote healthy outcomes.
Choice D rationale
While a healthy diet is crucial during pregnancy, the exact amount of weight gained does matter for both maternal and fetal health outcomes. Excessive or insufficient weight gain can lead to various complications, including gestational diabetes, preeclampsia, preterm birth, and abnormal fetal growth, thus specific weight gain targets are important.
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