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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Blood volume increases significantly within the first few weeks of gestation and increases progressively throughout the pregnancy.
The total blood volume increase varies from 20% to 100% above prepregnancy levels, usually close to 45%1.
Choice A is incorrect because the increase is usually close to 45%, not 20% to 25%.
Choice C is incorrect because the increase is usually close to 45%, not 50% to 55%.
Choice D is incorrect because the increase is usually close to 45%, not 30% to 35%.

A. Apply a pelvic girdle. B. Place the client in a supine position. C. Elevate the head of the bed. D. Elevate the foot of the bed.

Correct Answer is C

Explanation

Elevating the head of the bed can help to reduce pressure on the cervical spine and promote comfort for the client.
Choice A is not correct because a pelvic girdle is not used with halo traction.
Choice B is not correct because placing the client in a supine position can increase pressure on the cervical spine.
Choice D is not correct because elevating the foot of the bed would not provide any benefit for a client in halo traction.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nursing instructor is preparing to illustrate the various changes between the nonpregnant and pregnant female bodies. The instructor should point out that the blood volume in the pregnant woman can increase by what percentage?

Correct Answer is B

Explanation

A nurse is caring for a client who has been placed in halo traction to immobilize his cervical spine. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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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?