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A nurse is assessing a client who delivered an infant vaginally 2 days ago and notes that the fundus is firm, midline, and at the level of the umbilicus, lochia rubra is moderate, and there are no clots present in the lochia flow.
Which of the following actions should the nurse take?
Document findings as normal.
The fundus is the upper part of the uterus that contracts after delivery to prevent bleeding. The fundus should be firm, midline, and at the level of the umbilicus or lower on the second postpartum day. Lochia rubra is the normal bloody discharge that occurs for the first few days after delivery and should not contain large clots. The normal range of lochia rubra is scant to moderate.
Massage fundus until it becomes firm is wrong because the fundus is already firm and does not need further stimulation.
Administer oxytocin (Pitocin) is wrong because oxytocin is a medication that helps the uterus contract and is not indicated for a firm fundus.
Increase IV fluid rate is wrong because IV fluids are not related to the assessment of the fundus and lochia and may cause fluid overload.
The correct answer is choice A) Document findings as normal.
The fundus is the upper part of the uterus that contracts after delivery to prevent bleeding. The fundus should be firm, midline, and at the level of the umbilicus or lower on the second postpartum day. Lochia rubra is the normal bloody discharge that occurs for the first few days after delivery and should not contain large clots. The normal range of lochia rubra is scant to moderate.
Choice B) Massage fundus until it becomes firm is wrong because the fundus is already firm and does not need further stimulation.
Choice C) Administer oxytocin (Pitocin) is wrong because oxytocin is a medication that helps the uterus contract and is not indicated for a firm fundus.
Choice D) Increase IV fluid rate is wrong because IV fluids are not related to the assessment of the fundus and lochia and may cause fluid overload.