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 C
Explanation
Choice C rationale
Postpartum blues are characterized by tearfulness, insomnia, lack of appetite, and a feeling of letdown. These symptoms are common and usually resolve within a few weeks without medical intervention.
Choice A rationale
The letting-go phase occurs when the woman has assumed responsibility for caring for herself and her infant. It is not associated with the symptoms described.
Choice B rationale
Postpartum fatigue can cause tiredness and lack of energy but does not typically include tearfulness and a feeling of letdown.
Choice D rationale
Postpartum psychosis is a severe mental health condition that includes symptoms such as hallucinations, delusions, and severe mood swings. It is not characterized by the milder symptoms described. .
Correct Answer is A
Explanation
Choice A rationale
Ambulation is crucial in preventing thrombophlebitis as it promotes blood circulation and prevents blood stasis, which can lead to clot formation.
Choice B rationale
Warm, moist soaks can provide comfort but do not significantly contribute to preventing thrombophlebitis.
Choice C rationale
Bed rest increases the risk of thrombophlebitis due to decreased circulation and blood stasis.
Choice D rationale
Placing pillows under the knees can impede blood flow and increase the risk of clot formation.