While assessing a client during the fourth stage of labor, the nurse notes that the perineal pad is soaked with approximately 75 mL of lochia rubra.
Which nursing action is the priority?

Document the amount and type of lochia.

Accompany the client to the bathroom to empty her bladder.

Measure the client's hemoglobin and hematocrit levels.

Assess the client's uterine fundus.

Answer and Explanation

The Correct Answer is D

Choice A rationale

While documentation of lochia amount and type is a necessary component of ongoing assessment, it is not the priority over directly assessing the physiological state of the uterus in the fourth stage of labor. Lochia is the normal discharge of blood, mucus, and uterine tissue post-delivery. A soaked pad (approximately 75 mL) of lochia rubra within a short period suggests a need to check the uterine tone immediately, as uterine atony is the primary cause of early postpartum hemorrhage.

Choice B rationale

Although a distended bladder can displace the uterus and impair its contractility, causing excessive bleeding, the direct physical assessment of the fundus (Choice D) is the priority. Emptying the bladder is an important intervention if the uterus is found to be boggy and displaced; however, the nurse must first confirm the status of the uterine fundus to rule out or quickly address uterine atony, which is a life-threatening complication.

Choice C rationale

Measuring hemoglobin and hematocrit provides valuable retrospective data about the client's blood loss status, but it is not an immediate action that will prevent further blood loss. The priority is to implement a direct, immediate intervention to stop or reduce hemorrhage. The lab results would only reflect the effect of the hemorrhage, whereas assessing the fundus helps determine the cause and guides immediate treatment. The normal range for Hgb is 12 to 16 g/dL and Hct is 37 to 47 percent.

Choice D rationale

Assessing the uterine fundus is the priority because a large amount of lochia rubra (which is bright red, blood-like) indicates potential postpartum hemorrhage. The most common cause is uterine atony, a failure of the uterus to contract and compress the placental vessels. A firm, well-contracted fundus above the symphysis pubis prevents hemorrhage, so immediate palpation confirms the presence of uterus firmness and height and guides the next intervention, such as massage.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is ["A","B","D","E"]

Explanation

Choice A rationale

Uterine atony is the leading cause of postpartum hemorrhage, resulting in significant blood loss and hypovolemia. Increasing intravenous fluid replacement with crystalloid solutions (e.g., normal saline or lactated Ringer's) is critical to restoring circulating blood volume, maintaining hemodynamic stability, and preventing hypovolemic shock.

Choice B rationale

A full bladder can displace the uterus and impede its ability to contract effectively, contributing to or worsening uterine atony. Inserting an indwelling urinary catheter (Foley catheter) ensures continuous bladder drainage and decompression, allowing the uterus to move into its proper place and contract more effectively.

Choice C rationale

Monitoring deep tendon reflexes (DTRs) is primarily an assessment for magnesium sulfate toxicity in clients being treated for preeclampsia or eclampsia. While relevant in those specific conditions, it is not a direct intervention for managing the immediate effects or cause of postpartum hemorrhage due to uterine atony. Normal DTR response is 2+.

Choice D rationale

Quantifying blood loss is essential for determining the severity of the hemorrhage and the efficacy of interventions. Initiating a peri-pad count and accurately weighing the pads provides a reliable, though often underestimated, measure of blood loss, guiding the need for additional fluids, blood products, or uterotonic medications.

Choice E rationale

Uterine atony is a failure of the uterine muscle to contract and compress the blood vessels at the placental site. Performing a fundal massage stimulates the myometrium to contract, thereby physically compressing the vessels and activating the natural physiological mechanisms to stop the bleeding; this is a primary, initial intervention.

Choice F rationale

Tocolytic therapy, such as terbutaline or nifedipine, works by relaxing the uterine muscle, which is used to stop preterm labor. In the context of uterine atony, the goal is to contract the uterus, so administering tocolytic therapy would be contraindicated as it would worsen the atony and accelerate blood loss.

A. Appropriate for gestational age, term. B. Large for gestational age, term. C. Large for gestational age, preterm. D. Appropriate for gestational age, preterm.

Correct Answer is B

Explanation

Choice A rationale

Appropriate for gestational age (AGA) refers to neonates whose weight falls between the 10th and 90th percentiles for their gestational age. The neonate is term (38 weeks), but weighs 4,017 grams, which is >4,000 grams and classified as macrosomic, thus >90th percentile and not AGA. The classification of AGA is based on a statistical growth curve and is distinct from being macrosomic.

Choice B rationale

Large for gestational age (LGA) describes neonates whose weight is above the 90th percentile for their gestational age, which includes those with macrosomia (birth weight >4,000 g). This neonate weighs 4,017 g, placing them in the LGA category. Term is defined as a birth occurring between 37 weeks 0 days and 41 weeks 6 days gestation, making 38 weeks a term birth.

Choice C rationale

Large for gestational age (LGA) is correct for this 4,017 g neonate, as their weight exceeds the 90th percentile for 38 weeks' gestation. However, preterm refers to births occurring before 37 weeks 0 days gestation. Since this neonate was born at 38 weeks' gestation, the "preterm" classification is incorrect because 38 weeks is within the term range.

Choice D rationale

Appropriate for gestational age (AGA) is incorrect because this neonate's weight of 4,017 g is greater than the 90th percentile for a 38-week gestation, classifying them as large for gestational age (LGA). Term is correct as the neonate was born at 38 weeks' gestation, which is within the 37 weeks 0 days to 41 weeks 6 days range, making the overall classification inaccurate.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

While assessing a client during the fourth stage of labor, the nurse notes that the perineal pad is soaked with approximately 75 mL of lochia rubra. Which nursing action is the priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a postpartum client with suspected uterine atony. Which interventions would the nurse initiate to improve the patient's status? Select all that apply.

Correct Answer is ["A","B","D","E"]

Explanation

What would the nurse document after assessing a neonate born at 38 weeks' gestation who weighs 8 lb 13.1 oz (4,017 g)?

Correct Answer is B

Explanation

The nurse is assessing a new mother at a health care facility. Which symptom would the nurse identify as a symptom of postpartum blues?

A client with a history of three spontaneous abortions is now at 16 weeks' gestation and expresses a concern about remaining at home during pregnancy. Which query will elicit a response most helpful to the nurse developing the client's plan of care?

A postpartum client is being treated with subcutaneous heparin for deep vein thrombosis of the left calf. Which client assessment is of most concern to the nurse?

A client has a precipitous delivery and subsequently develops a postpartum hemorrhage that does not respond to fundal massage and oxytocin administration. What is the nurse's next action?

On the third postpartum day after an unexpected cesarean birth, the nurse finds the client crying. The client states, "I know my baby is fine, but I can't help crying. I wanted a natural childbirth so much. Why did this have to happen to me?" What is the nurse's best response to the client?

While assessing a client during the fourth stage of labor, the nurse notes that the perineal pad is soaked with approximately 75 mL of lochia rubra.
Which nursing action is the priority?