Which of the following findings should alert a nurse assessing a client who is 8 hr postpartum and multiparous?

Fundus three fingerbreadths above the umbilicus.

Moderate lochia rubra.

Blood pressure 130/84 mm Hg.

Moderate swelling of the labia.

Answer and Explanation

The Correct Answer is A

Choice A rationale
A fundus that is three fingerbreadths above the umbilicus 8 hours postpartum is a sign of urinary retention, which can displace the uterus and inhibit uterine contraction, leading to postpartum hemorrhage.
Choice B rationale
Moderate lochia rubra, or bloody discharge, is normal within the first few days after childbirth.
Choice C rationale
A blood pressure of 130/84 mm Hg is within the normal range for a postpartum woman.
Choice D rationale
Moderate swelling of the labia can be a normal finding after a vaginal birth.

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Correct Answer is A

Explanation

The nurse should first assess the fundus of the uterus. If the uterus is not firm (boggy), it may not be contracting well enough to compress the blood vessels and stop the bleeding. The nurse should massage the fundus until it is firm.

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

Correct Answer is D

Explanation

Choice A rationale
Flexing the knee while resting does not typically alleviate the symptoms of a possible DVT15161718.
Choice B rationale
Applying cold compresses is not typically recommended for the symptoms of a possible DVT15161718.
Choice C rationale
Massaging the area is not recommended, especially if the patient is showing signs of a possible DVT, as it could dislodge a clot.

Choice D rationale
Elevating the leg can help reduce swelling and improve blood flow, which can help alleviate pain associated with a possible DVT15161718.

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Which of the following findings should alert a nurse assessing a client who is 8 hr postpartum and multiparous?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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