The nurse assesses the postpartum patient to have moderate lochia ...

[penza]

The nurse assesses the postpartum patient to have moderate lochia rubra with clots. Which nursing intervention would be appropriate?
 
  1. Assess fundus and bladder status.
  2. Catheterize the patient.
  3. Administer Methergine IM per order.
  4. Contact the physician immediately.

Question 2

The nurse is admitting a patient with possible hydramnios. Hydramnios most likely would be suspected when:
 
  1. There is less amniotic fluid than normal for gestation.
  2. The fundal height increases disproportionately to the gestation.
  3. The woman has a twin gestation.
  4. The quadruple screen comes back positive.

[BUTTHOL369]

Answer to Question 1

1
Rationale 1: The nurse assesses the fundus and bladder status first. Moderate lochia, even with clots, might be related to the patient's supine position for several hours, or to other factors.
Rationale 2: Catheterizing the patient might be an intervention if the bladder is full and the patient is unable to void, but it is not the initial intervention.
Rationale 3: It is not necessary to administer Methergine IM per order; the situation does not warrant this intervention.
Rationale 4: It is not necessary to contact the physician immediately; the situation does not warrant this intervention.

Answer to Question 2

2
Rationale 1: Hydramnios occurs when there is more amniotic fluid than normal for gestation.
Rationale 2: The increased amount of amniotic fluid increases the fundal height disproportionately to the gestation.
Rationale 3: Hydramnios is not suspected simply by virtue of a twin gestation.
Rationale 4: A positive quadruple screen is not indicative of hydramnios.