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 B
Explanation
Choice A rationale
Hemorrhage is not prevented by walking. Hemorrhage management involves monitoring and medical interventions, not ambulation.
Choice B rationale
Walking helps prevent blood clots by promoting circulation. Postoperative patients are encouraged to ambulate early to reduce the risk of deep vein thrombosis (DVT) and pulmonary embolism.
Choice C rationale
Breast engorgement is managed through breastfeeding or pumping, not walking. Ambulation does not directly affect breast engorgement.
Choice D rationale
Rupture of amniotic membranes is not relevant postpartum. This condition is related to labor and delivery, not postoperative care.
Correct Answer is B
Explanation
Choice A rationale
Placing the client on seizure precautions is not appropriate for shaking chills during the immediate postpartum period. Shaking chills are a common physiological response after childbirth due to hormonal changes and the body’s effort to regulate temperature. Seizure precautions are reserved for clients with a history of seizures or those exhibiting signs of a seizure disorder.
Choice B rationale
Covering the client with warm blankets is the correct action. Shaking chills are often due to the body’s attempt to regain thermal balance. Providing warmth with blankets helps to alleviate the chills and provide comfort to the client.
Choice C rationale
Determining the client’s temperature is important but not the immediate action to take. While it is necessary to monitor for fever, which could indicate an infection, the priority is to provide comfort and warmth to the client experiencing chills.
Choice D rationale
Notifying the charge nurse is not the immediate action required. The nurse should first address the client’s immediate need for warmth and comfort. If the chills persist or are accompanied by other concerning symptoms, then notifying the charge nurse would be appropriate.