A nurse is collecting data from a client who is 1 day postpartum.Which of the following findings requires immediate intervention by the nurse?
Decreased urge to void.
Displaced fundus from the midline.
Fundal height below the umbilicus.
Increased urine output.
The Correct Answer is B
Choice A rationale
A decreased urge to void is a common postpartum finding due to the effects of anesthesia and the trauma of childbirth. It does not require immediate intervention unless it leads to bladder distention.
Choice B rationale
A displaced fundus from the midline, especially if it is accompanied by a boggy uterus, indicates uterine atony, which can lead to postpartum hemorrhage. Immediate intervention is required to prevent severe blood loss.
Choice C rationale
A fundal height below the umbilicus is an expected finding 1 day postpartum as the uterus begins to involute. This does not require immediate intervention.
Choice D rationale
Increased urine output is common in the postpartum period as the body eliminates excess fluid accumulated during pregnancy. This is not a cause for immediate concern.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is A
Explanation
Choice A rationale
Ambulation is crucial in preventing thrombophlebitis as it promotes blood circulation and prevents blood stasis, which can lead to clot formation.
Choice B rationale
Warm, moist soaks can provide comfort but do not significantly contribute to preventing thrombophlebitis.
Choice C rationale
Bed rest increases the risk of thrombophlebitis due to decreased circulation and blood stasis.
Choice D rationale
Placing pillows under the knees can impede blood flow and increase the risk of clot formation.
Correct Answer is B
Explanation
Choice A rationale
Urinary tract infections (UTIs) are not typically associated with increased lochia. UTIs usually present with symptoms such as burning during urination, frequent urination, and lower abdominal pain.
Choice B rationale
Lochia can pool in the vagina while lying in bed, leading to a larger amount being expelled upon standing. This is a normal occurrence and not a cause for concern.
Choice C rationale
Retained fragments of the placenta can cause heavy bleeding and infection, but the sudden expulsion of a large amount of lochia upon standing is more likely due to pooling rather than retained placenta.
Choice D rationale
The amount of lochia typically decreases over time during the postpartum period. An increase in lochia is not expected and should be evaluated for other causes.