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Author Question: The nurse has completed a postpartum assessment on a client who delivered an hour ago. Which amount ... (Read 70 times)

elizabeth18

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The nurse has completed a postpartum assessment on a client who delivered an hour ago. Which amount of lochia consists of a moderate amount?
 
  a. Saturated peripad
  b. 4- to 6-inch stain on the peripad
  c. 1- to 4-inch stain on the peripad
  d. Less than a 1-inch stain on the peripad

Question 2

To assess fundal contraction 6 hours after cesarean birth, which action should the nurse perform?
 
  a. Assess lochial flow rather than palpating the fundus.
  b. Palpate forcefully through the abdominal dressing.
  c. Place hands on both sides of the abdomen and press downward.
  d. Gently palpate, applying the same technique used for vaginal deliveries.



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amynguyen1221

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Answer to Question 1

ANS: B
Because estimating the amount of lochia is difficult, nurses frequently record flow by estimating the amount of lochia in 1 hour using the following labels:
 Scantless than a 1-inch stain on the peripad
 Light1- to 4-inch stain
 Moderate4- to 6-inch stain
 Heavysaturated peripad
 Excessivesaturated peripad in 15 minutes
Determining the time interval that the peripad is in place is also important. Lochia is less for women who have had a cesarean birth because some of the endometrial lining is removed during surgery.

Answer to Question 2

ANS: D
Assessment of the fundus is the same for vaginal and cesarean deliveries. Forceful palpation should never be used. The top of the fundus, not the sides, should be palpated and massaged. Assessing lochial flow is not adequate; the fundus also needs to be checked.





 

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