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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 D

Explanation

Choice D rationale

Applying an ice pack to the perineum is the recommended action for unrelieved episiotomy pain within the first 24 hours following delivery. Ice helps reduce swelling and provides pain relief.

Choice A rationale

Placing a soft pillow under the client’s buttocks is not effective and can increase pressure and swelling on the perineal area, worsening the pain.

Choice B rationale

Positioning a heating lamp toward the episiotomy is not recommended as it can increase the risk of burns and does not effectively reduce swelling.

Choice C rationale

Preparing a warm sitz bath can be beneficial after the first 24 hours but is not the initial action for unrelieved pain within the first 8 hours.

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.

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