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
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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Naxlex Comprehensive Predictor Exams
Related Questions
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 hips and buttocks and can help reduce swelling and discomfort in the perineal area after delivery.A warm sitz bath can also ease the pain of urination and promote blood flow to the area for faster healing.
Choice A is wrong because applying heat to the perineum can increase inflammation and pain.Choice B is wrong because using an ice pack on the perineum can cause an uncomfortable, sudden sensation of coldness on the skin.Choice D is wrong because using a heating pad on the abdomen has no effect on the perineal area and can also increase inflammation.
Correct Answer is C
Explanation
The correct answer is choice C.“I should report foul odor.” This indicates an understanding of the teaching because foul odor is a sign of infection and should be reported to the healthcare provider.Lochia is the normal vaginal discharge after childbirth that contains blood, mucus, uterine tissue and other materials.It has three stages: lochia rubra (red), lochia serosa (pinkish brown) and lochia alba (yellowish white).Lochia usually lasts for four to eight weeks.
Choice A is wrong because heavy bleeding is expected for the first few days after delivery and then gradually decreases.However, if the bleeding is excessive or does not slow down, it could indicate a postpartum hemorrhage and should be reported immediately.
Choice B is wrong because abdominal pain is normal after delivery as the uterus contracts and shrinks back to its pre-pregnancy size.However, if the pain is severe or does not improve with pain medication, it could indicate a complication such as infection or retained placenta and should be reported.
Choice D is wrong because perineal itching is common after delivery due to healing of the tissues and stitches.However, if the itching is accompanied by redness, swelling, discharge or fever, it could indicate an infection and should be reported.
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