NCLEX
A nurse is caring for a client that is currently experiencing postpartum hemorrhage. Which of the following actions is the nurse’s priority?
Correct response is D) Massage the fundus in a circular motion - first line of action to stimulate uterine contractions and remove placental fragments.
Wormer, K. C. (2024). Postpartum hemorrhage. StatPearls [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK499988/#article-27638.s13
True or False: It is a normal finding for lochia to change from alba to rubra post-delivery.
False -> can indicate a larger problem such as hemorrhaging or subinvolution.
Assessment Technologies Institute. (2023). RN Maternal Newborn Nursing (12th ed) Assessment Technologies Institute LLC
List out the acronym REEDA
R: Redness: can indicate infection
E: Edema: indicate swelling that impedes healing
E: Ecchymosis: indicates bruising or trauma
D: Discharge: indicate infection
A: Approximation of skin: if wounds are not close, it can indicate poor healing
Pebolo, P. F., Judith, A., & Dan, K. K. (2020). Episiotomy related morbidities measured using redness, edema, ecchymosis, discharge and apposition scale and numerical pain scale among primiparous women in Mulago National Referral Hospital, Kampala, Uganda. The Pan African medical journal, 36, 347. https://doi.org/10.11604/pamj.2020.36.347.25049
A nurse is preparing to assess a client that had a Cesarean delivery 30 minutes ago. Which of the following findings require immediate intervention from the nurse?
A) Blood Pressure of 132/86
B) Heavy saturated lochia in under 15 minutes
C) Heart Rate of 89
D) Mild cramping on a 5/10 pain scale
Correct Answer is B) Heavy saturated lochia in under 15 minutes indicates excessive bleeding and requires immediate intervention (ATI)
A) BP of 140/90 or higher is a significant indicator of PPH, 132/86 is a normal finding.
C) HR of 89 is a normal finding, 100+ is an abnormal finding.
D) Mild cramping and pain should be addressed, but there is another priority that needs more attention.
Assessment Technologies Institute. (2023). RN Maternal Newborn Nursing (12th ed) Assessment Technologies Institute LLC