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
Massaging the area is not recommended as it can dislodge a clot and cause it to travel to the lungs, leading to a pulmonary embolism. This can be life-threatening and should be avoided.
Choice B rationale
Elevating the leg helps to reduce swelling and pain by promoting venous return. This is a standard intervention for managing symptoms of deep vein thrombosis (DVT) and helps prevent further complications.
Choice C rationale
Applying cold compresses is not effective for DVT. Cold compresses are generally used to reduce inflammation and pain in acute injuries, but they do not address the underlying issue of a blood clot.
Choice D rationale
Flexing the knee while resting can increase the risk of clot dislodgement and is not recommended. Keeping the leg straight and elevated is a safer approach to managing DVT symptoms.
Correct Answer is C
Explanation
Choice A rationale
Checking blood pressure is important but not the first action to control bleeding.
Choice B rationale
Observing the client is necessary but not the immediate action to control bleeding.
Choice C rationale
Massaging the fundus helps the uterus contract and can reduce bleeding, which is crucial in managing postpartum hemorrhage.
Choice D rationale
Administering oxytocin is important but should follow fundal massage to ensure the uterus is contracting.