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, and the fundus is midline and firm at the
umbilicus.
Which of the following actions should the nurse take?
Assist the client to ambulate
Perform fundal massage
Increase the rate of the IV fluids
Check for blood under the client's buttocks
The Correct Answer is D
Choice A rationale:
Assisting the client to ambulate is not the immediate action required in this scenario. The nurse has found a small amount of
lochia rubra on the client’s perineal pad, and the fundus is midline and firm at the umbilicus. These are normal findings for a
client who is 4 hours postpartum. However, the nurse should ensure that there is no excessive bleeding, which could be a sign
of postpartum hemorrhage.
Choice B rationale:
Performing a fundal massage is not necessary in this case. Fundal massage is usually performed when the uterus is boggy or
soft, which could indicate uterine atony, a leading cause of postpartum hemorrhage. In this scenario, the fundus is firm and at
the level of the umbilicus, which is a normal finding 4 hours postpartum.
Choice C rationale:
Increasing the rate of IV fluids is not the immediate action required in this scenario. IV fluids are usually increased to expand
intravascular volume in cases of postpartum hemorrhage. In this case, the nurse has found a small amount of lochia rubra on
the client’s perineal pad, which is a normal finding 4 hours postpartum.
Choice D rationale:
Checking for blood under the client’s buttocks is the correct action for the nurse to take in this scenario. This is to ensure that
there is no excessive bleeding, which could be hidden under the client’s buttocks. Excessive bleeding could be a sign of
postpartum hemorrhage, a potentially life-threatening complication.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Umbilical cord compression is the most common cause of variable decelerations. It occurs when the umbilical cord is
compressed, momentarily reducing blood flow to the fetus and causing a decrease in fetal heart rate.
Variable decelerations are characterized by their abrupt onset, variable duration, and unpredictable shape. They typically
recover quickly to the baseline fetal heart rate after the compression is relieved.
Several factors can contribute to umbilical cord compression, including:
Fetal movement: The fetus can sometimes move in a way that compresses the cord, especially during active labor.
Oligohydramnios (low amniotic fluid): With less amniotic fluid, there's less cushioning around the cord, making it more prone
to compression.
Nuchal cord (cord around the neck): If the cord is wrapped around the fetus's neck, it can become compressed during
contractions.
Short umbilical cord: A shorter cord has less slack, increasing the risk of compression.
Choice B rationale:
Maternal hypotension can cause fetal heart rate decelerations, but these typically present as late decelerations, not variable
decelerations. Late decelerations have a gradual onset, a uniform shape, and typically occur after the peak of a contraction.
Maternal hypotension can decrease placental blood flow, leading to fetal hypoxia (decreased oxygen supply). This hypoxia can
then trigger a decrease in fetal heart rate.
Choice C rationale:
The fetal sleep cycle does not typically cause variable decelerations in the fetal heart rate. During sleep, the fetal heart rate
may exhibit a decrease in baseline variability, but this is not the same as variable decelerations.
Choice D rationale:
The use of epidural anesthesia can sometimes cause a decrease in fetal heart rate variability, but it does not typically cause
variable decelerations. Epidural anesthesia can lead to maternal hypotension, which, as mentioned earlier, can cause late
decelerations.
Correct Answer is D
Explanation
Choice A rationale:
Fetal attitude in general flexion is not a contributing factor to difficult, prolonged labor. In fact, it is the normal fetal attitude
during labor. The fetus is typically in a position of general flexion, where the head is flexed forward, chin to chest, and the arms
and legs are flexed, with the arms crossed over the chest and the legs bent at the knees.
Choice B rationale:
Fetal lie being longitudinal is the normal and most common fetal lie during labor. In a longitudinal lie, the long axis of the fetus
is parallel with the long axis of the mother. This is the ideal and most common position for labor and delivery.
Choice C rationale:
A gynecoid pelvis is the most common type of female pelvis and is the most favorable for childbirth. It has a round shape with
a wide pubic arch, which allows for easier passage of the baby during delivery.
Choice D rationale:
A persistent occiput posterior (OP) position can indeed contribute to difficult, prolonged labor. In an OP position, the baby’s
occipital bone is towards the mother’s posterior side. This position can cause labor to be more painful and last longer because the baby’s head diameter that presents to the birth canal is larger. It can also cause back pain during labor, often referred to as "back labor"1.
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