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.
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Correct Answer is C
Explanation
Choice C rationale
Checking the fundus helps determine if the uterus is contracting properly, which is essential in managing postpartum bleeding.
Choice A rationale
Measuring vital signs is important but not the first action to control bleeding.
Choice B rationale
Requesting a vaginal examination is necessary but not the immediate action to control bleeding.
Choice D rationale
Feeling for a full bladder is important but not the first action to control bleeding.
Correct Answer is D
Explanation
Choice A rationale
Rho(D) immune globulin is not indicated if both the client and the newborn are Rh positive. There is no risk of Rh incompatibility in this scenario.
Choice B rationale
Similarly, if both the client and the newborn are Rh positive, there is no need for Rho(D) immune globulin.
Choice C rationale
If both the client and the newborn are Rh negative, there is no risk of Rh incompatibility, and Rho(D) immune globulin is not needed.
Choice D rationale
Rho(D) immune globulin is indicated when the client is Rh negative and the newborn is Rh positive. This prevents the development of Rh antibodies in the client, which could affect future pregnancies.