What action should a nurse take when caring for a client who is 1 hr postpartum and observes a large amount of lochia rubra and several small clots on the client’s perineal pad, with the fundus midline and firm at the umbilicus?
Notify the client’s provider.
Document the findings and continue to monitor the client.
Increase the frequency of fundal massage.
Encourage the client to empty her bladder.
The Correct Answer is B
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Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Assessing her skin for hydration and color can provide some information about the client’s overall health and nutritional status, but it doesn’t directly assess her diet.
Choice B rationale
Assessing a list she makes describing a good diet can provide information about the client’s knowledge of nutrition, but it doesn’t provide information about her actual dietary intake.
Choice C rationale
Asking her to describe her intake for the last week can provide a more accurate picture of her actual dietary habits and nutritional status.
Choice D rationale
Asking her to describe her total intake for a week during pregnancy can provide information about her dietary habits during pregnancy, but it doesn’t assess her current diet.
Correct Answer is D
Explanation
Choice A rationale
Vaginal discharge, or leukorrhea, often increases during pregnancy due to higher levels of estrogen and greater blood flow to the vaginal area. It does not typically decrease before labor.
Choice B rationale
Weight gain is expected during pregnancy, but a sudden gain of 0.5 to 1.3 kg is not a typical sign that labor is about to start.
Choice C rationale
Urinary retention is not a typical sign that labor is about to start. In fact, many women find that they need to urinate more frequently as labor approaches, due to increased pressure on the bladder.
Choice D rationale
A surge of energy, often called “nesting,” can be a sign that labor is about to start. Some women experience a burst of energy and the desire to prepare their home for the baby in the days or hours before labor begins.
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