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 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 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.