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?
Measure the client’s vital signs.
Request the provider perform a vaginal examination.
Check the client’s fundus.
Feel for a full bladder.
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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Correct Answer is C
Explanation
Choice A rationale
It is incorrect to say that birth control is not needed for at least six months. Ovulation can occur much sooner, and contraception should be discussed early.
Choice B rationale
Most people do not need birth control for three months is also incorrect. Ovulation can resume as early as three weeks postpartum.
Choice C rationale
Ovulation can occur within 27 days postpartum, making it important to discuss contraception early to prevent unintended pregnancies.
Choice D rationale
Agreeing with the statement is incorrect and can lead to misinformation. It is important to provide accurate information about postpartum ovulation and contraception.
Correct Answer is D
Explanation
Choice D rationale
Assisting the client to void is the first action the nurse should take. A full bladder can cause the fundus to deviate to the right and become boggy. Voiding helps the uterus contract and return to its normal position.
Choice A rationale
Inserting an indwelling urinary catheter may be necessary if the client is unable to void, but it is not the first action.
Choice B rationale
Administering methylergometrine to the client is not the first action. This medication stimulates uterine contractions and can help reduce postpartum bleeding, but the initial step is to address the full bladder.
Choice C rationale
Obtaining a stat hemoglobin level is important if there is a concern for significant blood loss, but it is not the first action.