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:
Significance of retraction: Retraction of the fetal head against the maternal perineum is a crucial sign that the fetal shoulders
are about to be delivered. It indicates that the fetal head has fully descended into the pelvic outlet and is ready to rotate and
deliver the shoulders.
Urgency of preparation: It's essential for the nurse to promptly prepare for the delivery of the shoulders to ensure a safe and
timely birth:
Gather necessary equipment, including sterile gloves, towels, and possibly a suction bulb.
Position the mother appropriately, often in a semi-sitting or lithotomy position, to facilitate delivery.
Support the perineum to reduce tearing and guide the delivery of the shoulders.
Communicate with the mother to encourage effective pushing and maintain clear instructions throughout the process.
Anticipate potential complications, such as shoulder dystocia, and be prepared to assist with maneuvers to resolve it if
necessary.
Choice B rationale:
Rest during second stage: While rest is important during labor, encouraging rest between contractions at this specific point
(retraction of the head) could delay the delivery of the shoulders, potentially increasing risks for both mother and baby.
Maintaining momentum: The second stage of labor typically involves active pushing and uterine contractions to facilitate
delivery. Resting at this stage could interrupt the natural progression of labor.
Choice C rationale:
Role of blood pressure monitoring: Monitoring blood pressure is essential throughout labor to detect potential complications
like preeclampsia or hemorrhage. However, in this specific scenario, where the fetal head is already retracted and the
shoulders are imminent, preparing for delivery takes priority over routine blood pressure checks.
Choice D rationale:
Oxygen administration: Oxygen is sometimes administered during labor to support the mother's and baby's oxygen levels.
However, it's not a standard intervention for all laboring women, and its necessity would be based on individual assessments
and clinical judgment. In the absence of specific indications for oxygen, such as maternal distress or fetal heart rate concerns,
it's not the priority action when the fetal head is retracted and delivery of the shoulders is impending.
Correct Answer is ["A","B","D"]
Explanation
Choice A rationale:
The client is in the second stage of labor because she is actively pushing and the fetal head is at the vaginal station.
The second stage of labor is defined as the time from full cervical dilation to the birth of the baby. It is characterized by strong,
regular contractions and the urge to push.
Decelerations in the fetal heart rate can occur during the second stage of labor due to a variety of factors, including head
compression, cord compression, and uteroplacental insufficiency.
Choice B rationale:
The nurse should apply an oxygen mask to the client to increase the oxygen supply to the fetus.
This can help to improve fetal heart rate and prevent further decelerations.
Oxygen is a vital nutrient for the fetus, and it is essential for maintaining a normal fetal heart rate.
When the fetal heart rate decelerates, it is a sign that the fetus is not getting enough oxygen.
Applying an oxygen mask to the mother can help to increase the amount of oxygen that is available to the fetus.
Choice D rationale:
The nurse should monitor the client's vital signs and fetal heart rate to assess the client's progress and the well-being of the
fetus.
Vital signs, such as blood pressure, pulse, and respiration rate, can provide important information about the mother's health
and how she is coping with labor.
The fetal heart rate is a direct measure of the fetus's well-being.
By monitoring these parameters, the nurse can identify any potential problems and intervene as needed.
Additional notes:
The nurse should also encourage the client to change positions, as this can help to relieve cord compression.
The nurse should also prepare for the possibility of a rapid delivery, as decelerations in the fetal heart rate can sometimes be a
sign of fetal distress.
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