A nurse is caring for a postpartum client who reports heavy bleeding and large clots in her lochia.

Which of the following actions should the nurse take?

Document the finding in the client’s chart

Encourage the woman to empty her bladder regularly

Palpate the fundus for firmness

Notify the provider

Answer and Explanation

The Correct Answer is C

The correct answer is choice C. Palpate the fundus for firmness. This is because uterine atony is the most common cause of postpartum hemorrhage and palpating the fundus can help assess the tone of the uterus and stimulate contractions. If the fundus is boggy or soft, the nurse should massage it gently until it becomes firm.

Choice A is wrong because documenting the finding in the client’s chart is not an immediate action to stop the bleeding and may delay the treatment.

Choice B is wrong because encouraging the woman to empty her bladder regularly is a preventive measure for postpartum hemorrhage, not a treatment. A full bladder can displace the uterus and prevent it from contracting properly.

Choice D is wrong because notifying the provider is not enough to manage postpartum hemorrhage. The nurse should initiate interventions such as oxytocin administration, uterine massage, bimanual compression, fluid replacement, and blood transfusion as needed.

Notifying the provider should be done after or along with these interventions.

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Correct Answer is C

Explanation

The correct answer is choice C.“Take a warm sitz bath.” A sitz bath is a shallow bath that covers the perineum and can help relieve pain and swelling after a vaginal birth with an episiotomy.A sitz bath can also promote healing and prevent infection by keeping the area clean.

Choice A is wrong because applying heat to the perineum can increase inflammation and delay healing.Choice B is wrong because using an ice pack on the perineum is only recommended for the first 24 hours after delivery to reduce swelling.After that, ice can cause tissue damage and slow down blood flow to the area.Choice D is wrong because using a heating pad on the abdomen has no effect on the perineal pain and can also cause burns or overheating.

Normal ranges for postpartum perineal pain vary depending on the type and degree of injury, but generally it should improve within a few weeks.If the pain persists or worsens, or if there are signs of infection such as fever, foul-smelling discharge, or redness, it is important to seek medical attention.

A. Lochia rubra on day 2 postpartum B. Lochia serosa on day 4 postpartum C. Lochia alba on day 10 postpartum D. Large clots on day 3 postpartum.

Correct Answer is D

Explanation

The correct answer is choice D. Large clots on day 3 postpartum.This is because large clots indicate excessive bleeding and may be a sign of postpartum hemorrhage, which is a rare but potentially fatal condition that requires immediate medical attention.

Choice A is wrong because lochia rubra, which is dark or bright red blood, is normal for the first three to four days after birth.

Choice B is wrong because lochia serosa, which is pinkish brown discharge that’s less bloody looking, is normal for four to 12 days after birth.

Choice C is wrong because lochia alba, which is yellowish white discharge with little to no blood, is normal from about 12 days to six weeks after birth.

Normal ranges for lochia are:

• Lochia rubra: lasts for three to four days, flows like a heavy period, small clots are normal.

• Lochia serosa: lasts for four to 12 days, flow is moderate, less clotting or no clots.

• Lochia alba: lasts from about 12 days to six weeks, light flow or spotting, no clots.

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A nurse is caring for a postpartum client who reports heavy bleeding and large clots in her lochia. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is 1 week postpartum and has a vaginal birth with an episiotomy. The client reports that she has pain in her perineal area and asks the nurse what she can do to relieve the discomfort. Which of the following responses should the nurse make?

Correct Answer is C

Explanation

A nurse is assessing the amount, color, odor, consistency, and presence of clots or tissue in the lochia of a postpartum client. Which of the following findings should the nurse report as abnormal?

Correct Answer is D

Explanation

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A nurse is caring for a postpartum client who has a boggy uterus. Which of the following actions should the nurse take?

A nurse is teaching a postpartum client about lochia and when to report abnormal findings. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is caring for a client who is 5 days postpartum and has a vaginal birth with an episiotomy. The client reports that she has pain in her perineal area and asks the nurse what she can do to relieve the discomfort. Which of the following responses should the nurse make?

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A nurse is caring for a postpartum client who reports heavy bleeding and large clots in her lochia.

Which of the following actions should the nurse take?