Question

A nurse is caring for a client who is 4 hr postpartum. The nurse finds a small amount of lochia rubra on the client's perineal pad. The funds is midline and firm at the umbilicus. Which of the following actions should the nurse take?

A. Assist the client to ambulate.
Rationale: The nurse is not addressing the client's needs by assisting her to ambulate; therefore, this is not an appropriate action for the nurse to take.
B. Perform fundal massage.
Rationale: The nurse notes that the funds is midline and firm; therefore, fundal massage is not indicated at this time.
C. Increase the rate of the IV fluids.
Rationale: There is no indication that the client requires extra fluid; therefore, this is not an appropriate action for the nurse to take.
D. Check for blood under the client's buttock.
Rationale: The nurse should check for blood under the client's buttock to evaluate the amount of lochia flow and to check for pooling of blood that would otherwise be missed.

Answer 1

The nurse should check for blood under the client's buttocks to assess for additional lochia flow or a hidden pool, since the fundus is midline and firm, indicating a normal postpartum uterus condition.

Step-by-step explanation:

The appropriate action for the nurse to take when caring for a client who is 4 hours postpartum with a small amount of lochia rubra on the perineal pad is to check for blood under the client's buttock. Since the fundus is midline and firm at the umbilicus, which is normal at this stage, a fundal massage is not indicated. Checking for blood under the buttocks would assess for additional lochia flow or pooled blood that may not be visible on the perineal pad and could indicate an issue such as a postpartum hemorrhage that needs to be addressed.