A nurse is caring for a client who is 4 hr 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?
Assist the client to ambulate.
Increase the rate of IV fluids.
Check for blood under the client's buttock.
Perform fundal massage.
The Correct Answer is C
The nurse should check for blood under the client’s buttocks.
A small amount of lochia rubra on the client’s perineal pad 4 hours postpartum is normal.
The fundus being midline and firm at the umbilicus is also a normal finding.
Choice A is incorrect because assisting the client to ambulate is not necessary at this time.
Choice B is incorrect because there is no need to increase the rate of IV fluids.
Choice D is incorrect because performing a fundal massage is not necessary since the fundus is already firm and midline.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
One of the common symptoms of autism spectrum disorder (ASD) is difficulty with social communication and interaction, which can include avoiding or not keeping eye contact.
Choice B is not an answer because sitting quietly in the caregiver’s lap during the interview is not a typical symptom of ASD.
Choice C is not an answer because smiling when shown a stuffed animal is not a typical symptom of ASD.
Choice D is not an answer because crying and running to the door when the caregiver leaves the room is not typical symptom of ASD.
Correct Answer is C
Explanation
The MSAFP test measures the levels of alpha-fetoprotein (AFP) in the mother’s body.
AFP is a protein produced by the baby during pregnancy.
Too much AFP in the mother’s body may indicate that the baby is at risk of a neural tube defect, like spina bifida.
Choice A is incorrect because this test does not screen for gestational diabetes.
Choice B is incorrect because this test does not screen for fetal maturity.
Choice D is incorrect because this test does not screen for ABO incompatibility.
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