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 A
Explanation
Choice A rationale
The client needs a second varicella vaccination at her postpartum visit to ensure full immunity. The initial dose provides partial immunity, and the second dose completes the vaccination series.
Choice B rationale
The client needs to use contraception for 1 month, not 3 months, before considering pregnancy after receiving the varicella vaccine. This is to prevent potential harm to a developing fetus.
Choice C rationale
The varicella vaccine is not given based on the baby’s blood type. It is administered to protect the client from varicella infection.
Choice D rationale
There is no need for testing to see if the client has developed immunity after receiving the varicella vaccine. The second dose is given to ensure full immunity.
Correct Answer is B
Explanation
Choice B rationale
A heart rate of 110/min is a sign of tachycardia, which can indicate a postpartum complication such as infection, hemorrhage, or other underlying conditions. Tachycardia requires immediate assessment and intervention.
Choice A rationale
Chills shortly following delivery can be a normal response to the body’s adjustment after childbirth and do not necessarily indicate a complication.
Choice C rationale
Urinary output of 3,000 mL/12 hr is high but can be a normal part of postpartum diuresis as the body eliminates excess fluid accumulated during pregnancy.
Choice D rationale
The fundus at the umbilicus level is a normal finding in the immediate postpartum period and does not indicate a complication.