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A nurse is collecting data from a postpartum client and finds a large amount of lochia rubra with several clots on the client’s perineal pad.Which of the following actions should the nurse take first?

A.

Measure the client’s vital signs.

B.

Request the provider perform a vaginal examination.

C.

Check the client’s fundus.

D.

Feel for a full bladder.

Answer and Explanation

The Correct Answer is C

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.


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View Related questions

Correct Answer is ["A","B","C"]

Explanation

Choice A rationale

Topical creams can help soothe and promote healing of the episiotomy or laceration site.

Choice B rationale

Sitz baths are effective in reducing pain and promoting healing by increasing blood flow to the perineal area.

Choice C rationale

Ice packs help reduce swelling and provide pain relief in the initial 24 hours post-delivery.

Choice D rationale

Tocolytics are not indicated for episiotomy or laceration care as they are used to suppress preterm labor.

Choice E rationale

Doing nothing is not appropriate as it does not address the pain or promote healing.

Correct Answer is B

Explanation

Choice A rationale

Placing the client on seizure precautions is not appropriate for shaking chills during the immediate postpartum period. Shaking chills are a common physiological response after childbirth due to hormonal changes and the body’s effort to regulate temperature. Seizure precautions are reserved for clients with a history of seizures or those exhibiting signs of a seizure disorder.

Choice B rationale

Covering the client with warm blankets is the correct action. Shaking chills are often due to the body’s attempt to regain thermal balance. Providing warmth with blankets helps to alleviate the chills and provide comfort to the client.

Choice C rationale

Determining the client’s temperature is important but not the immediate action to take. While it is necessary to monitor for fever, which could indicate an infection, the priority is to provide comfort and warmth to the client experiencing chills.

Choice D rationale

Notifying the charge nurse is not the immediate action required. The nurse should first address the client’s immediate need for warmth and comfort. If the chills persist or are accompanied by other concerning symptoms, then notifying the charge nurse would be appropriate.

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