Difficulty: Medium
Average Score: 93%
Simulated
Passage / Scenario
Postpartum client, large amount of lochia rubra with several clots on perineal padWhich of the following actions should the nurse take first?
Correct answer
B
Rationale
The correct action the nurse should take first is to check the client's fundus. This is prioritized because assessing the fundus helps determine the status of postpartum uterine involution and can indicate any signs of hemorrhage. By checking the fundus first, the nurse can promptly identify and address any abnormalities or complications. Measuring vital signs and feeling for a full bladder are important assessments but come after checking the fundus. Requesting a provider perform a vaginal examination is not the first action to take unless there are specific concerns or indications for it.