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
This is a sign of uterine hyperstimulation, which can cause fetal distress and excessive bleeding12.
The nurse should report this finding to the provider and monitor the fetal heart rate and maternal vital signs.
Choice B.
Early decelerations in the FHR are incorrect, as this is a normal finding during the second stage of labor, indicating head compression.
Choice C.
Pelvic pressure with contractions is incorrect, as this is an expected finding during the second stage of labor, indicating that the baby is descending through the birth canal.
Choice D.
Bloody show from the vagina is incorrect, as this is also an expected finding during the second stage of labor, indicating cervical dilation and effacement13.
Therefore, choice A is the best answer.
Correct Answer is B
Explanation
28 to 40 pounds (13 to 18 kilograms).
Women with a low BMI (under 18.5) should gain between 28 to 40 pounds (13 to 18 kilograms) throughout their pregnancy.
Choice A, 15 to 25 pounds (7 to 11 kilograms), is incorrect because it is the recommended weight gain for women who are overweight before pregnancy.
Choice C, 16 to 30 pounds (7.25 to 14 kilograms), is incorrect because it does not fall within the recommended weight gain range for women with a low BMI.
Choice D, 25 to 35 pounds (11 to 16 kilograms), is incorrect because it is the recommended weight gain for women who are at a healthy weight before pregnancy.
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