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
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.
Correct Answer is A
Explanation
Choice A rationale
Completely emptying each breast at each feeding or using a pump helps prevent milk stasis, which can lead to mastitis. Ensuring the breasts are fully emptied reduces the risk of blocked ducts and infection.
Choice B rationale
Nursing on only the unaffected breast can lead to engorgement and worsening of mastitis in the affected breast. It is important to continue breastfeeding on both sides to maintain milk flow and prevent complications.
Choice C rationale
Wearing a tight-fitting bra can restrict milk flow and exacerbate mastitis. A well-fitting, supportive bra is recommended to avoid further complications.
Choice D rationale
Limiting the time the infant nurses on each breast can lead to incomplete emptying and increase the risk of mastitis. It is important to ensure the breasts are fully emptied to prevent infection.