After a client has a C-section she needs to get up and take short walks to prevent what?
Hemorrhage.
Blood clots.
Breast engorgement.
Rupture of amniotic membranes.
The Correct Answer is B
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.
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Correct Answer is B
Explanation
Choice A rationale
A decreased urge to void is a common postpartum finding due to the effects of anesthesia and the trauma of childbirth. It does not require immediate intervention unless it leads to bladder distention.
Choice B rationale
A displaced fundus from the midline, especially if it is accompanied by a boggy uterus, indicates uterine atony, which can lead to postpartum hemorrhage. Immediate intervention is required to prevent severe blood loss.
Choice C rationale
A fundal height below the umbilicus is an expected finding 1 day postpartum as the uterus begins to involute. This does not require immediate intervention.
Choice D rationale
Increased urine output is common in the postpartum period as the body eliminates excess fluid accumulated during pregnancy. This is not a cause for immediate concern.
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.