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 B
Explanation
Choice A rationale
Turning the newborn’s head quickly to one side does not elicit the Moro reflex. This action can elicit the tonic neck reflex, also known as the “fencing” reflex.
Choice B rationale
Performing a sharp hand clap near the infant can elicit the Moro reflex. This reflex is a response to a sudden loss of support and involves three distinct components: spreading out the arms (abduction), unspreading the arms (adduction), and usually crying.
Choice C rationale
Placing a finger at the base of the newborn’s toes elicits the Babinski reflex, not the Moro reflex.
Choice D rationale
Holding the newborn vertically allowing one foot to touch the table surface does not elicit the Moro reflex. This action can elicit the stepping or walking reflex.
Correct Answer is D
Explanation
Choice A rationale
Excessive uterine enlargement is a common finding in a client with a hydatidiform mole. This is due to the overgrowth of trophoblastic tissue, which forms the placenta.
Choice B rationale
Profuse, clear vaginal discharge is not typically associated with a hydatidiform mole. The most common symptom is vaginal bleeding, which can be dark brown or bright red, and sometimes is described as looking like prune juice.
Choice C rationale
An irregular fetal heart rate is not a typical finding in a client with a hydatidiform mole, as this condition often results in a nonviable pregnancy.
Choice D rationale
A rapid decline in human chorionic gonadotropin (hCG) levels is not expected in a client with a hydatidiform mole. In fact, hCG levels are usually abnormally high in these cases.
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