During ambulation to the bathroom, a postpartum client experiences a gush of dark red blood that soon stops.
On data collection, a nurse finds the uterus to be firm, midline, and at the level of the umbilicus.
Which of the following findings should the nurse interpret this data as being?

An indication of a cervical or perineal laceration.

Abnormally excessive lochia rubra flow.

A normal postural discharge of lochia.

Evidence of a possible vaginal hematoma.

Answer and Explanation

The Correct Answer is C

Choice A rationale

A cervical or perineal laceration would typically result in continuous bleeding rather than a gush that stops. The uterus would also not be firm and midline if there were a significant laceration.

Choice B rationale

Abnormally excessive lochia rubra flow would be continuous and not stop after a gush. The uterus being firm and midline indicates that the bleeding is not excessive.

Choice C rationale

A normal postural discharge of lochia occurs when pooled blood in the vagina is expelled upon standing or changing position. This is common and expected in the postpartum period.

Choice D rationale

A vaginal hematoma would present with localized pain and swelling, and the bleeding would not stop suddenly. The uterus being firm and midline also indicates that a hematoma is unlikely.

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Correct Answer is A

Explanation

Choice A rationale

At 1 cm above the umbilicus is the expected position of the uterine fundus 12 hours postpartum. After delivery, the fundus is typically at the level of the umbilicus and then descends approximately 1 cm per day. At 12 hours postpartum, it is normal for the fundus to be slightly above the umbilicus.

Choice B rationale

One fingerbreadth above the symphysis pubis is not the expected position of the fundus 12 hours postpartum. This position is more typical several days postpartum as the uterus continues to involute and return to its pre-pregnancy size.

Choice C rationale

To the right of the umbilicus is not a normal finding and may indicate a full bladder, which can displace the uterus. The nurse should assist the client to void and then reassess the fundal position.

Choice D rationale

Three fingerbreadths above the umbilicus is not expected 12 hours postpartum. This position may indicate uterine atony or subinvolution, which requires further assessment and intervention.

A. Massage the area. B. Elevate the leg. C. Apply cold compresses. D. Flex the knee while resting.

Correct Answer is B

Explanation

Choice A rationale

Massaging the area is not recommended as it can dislodge a clot and cause it to travel to the lungs, leading to a pulmonary embolism. This can be life-threatening and should be avoided.

Choice B rationale

Elevating the leg helps to reduce swelling and pain by promoting venous return. This is a standard intervention for managing symptoms of deep vein thrombosis (DVT) and helps prevent further complications.

Choice C rationale

Applying cold compresses is not effective for DVT. Cold compresses are generally used to reduce inflammation and pain in acute injuries, but they do not address the underlying issue of a blood clot.

Choice D rationale

Flexing the knee while resting can increase the risk of clot dislodgement and is not recommended. Keeping the leg straight and elevated is a safer approach to managing DVT symptoms.

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During ambulation to the bathroom, a postpartum client experiences a gush of dark red blood that soon stops.On data collection, a nurse finds the uterus to be firm, midline, and at the level of the umbilicus.Which of the following findings should the nurse interpret this data as being?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who is 12 hours postpartum following a spontaneous vaginal delivery.The nurse should expect to find the uterine fundus at which of the following positions on the client’s abdomen?

Correct Answer is A

Explanation

A client who is 7 days postpartum calls the provider’s office and reports pain, swelling, and redness of her left calf.Besides the client seeing the provider, which of the following interventions should the nurse suggest?

Correct Answer is B

Explanation

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During ambulation to the bathroom, a postpartum client experiences a gush of dark red blood that soon stops.
On data collection, a nurse finds the uterus to be firm, midline, and at the level of the umbilicus.
Which of the following findings should the nurse interpret this data as being?