A nurse is caring for a client who is 1 hr postpartum and observes a large amount of lochia rubra and several small clots on the client's perineal pad. The fundus is midline and firm at the umbilicus. Which of the following actions should the nurse take?

Correct Answer: A

Rationale: The correct answer is A: Document the findings and continue to monitor the client. This is the appropriate action because the client's fundus is midline and firm, indicating good uterine tone. Lochia rubra and small clots are expected findings in the immediate postpartum period. The nurse should document these findings for future reference and continue to monitor the client's condition. Choice B (Notify the client's provider) is incorrect because there are no concerning signs that warrant immediate provider notification, as the fundus is firm and midline. Choice C (Increase the frequency of fundal massage) is unnecessary since the fundus is already firm at the umbilicus, indicating good uterine tone. Choice D (Encourage the client to empty her bladder) is not the priority in this scenario, as the client's fundal assessment and lochia observations take precedence.

Correct Answer: B

Rationale: The correct answer is B: A surge of energy. This is because an increase in energy is often seen in pregnant women shortly before labor begins, known as the "nesting instinct." This burst of energy can indicate that the body is preparing for labor. A: Decreased vaginal discharge is not a sign that precedes labor. In fact, an increase in vaginal discharge is more common as labor approaches. C: Urinary retention is not a sign of labor onset. In late pregnancy, pressure on the bladder may cause frequent urination, but retention is not typical. D: Weight gain of 0.5 to 1.5 kg is not a specific sign of labor onset. Weight gain can fluctuate throughout pregnancy and is not a reliable indicator of impending labor.

Correct Answer: C

Rationale: The correct answer is C: Placing the newborn on mother's chest and abdomen. This promotes parental attachment through skin-to-skin contact, facilitating bonding and emotional connection. It also helps regulate the baby's temperature and encourage breastfeeding. Placing the infant under the radiant warmer (A) may disrupt immediate bonding. Allowing the mother to rest (B) is important, but promoting attachment should be prioritized. Taking the newborn to the nursery (D) can delay the crucial bonding process.

Correct Answer: D

Rationale: The correct answer is D because a breathing pattern that is diaphragmatic with sternal retractions indicates respiratory distress in a newborn, which is a critical condition requiring immediate attention. Staying logical, let's assess the other choices: A: Temperature of 97.7 degrees Fahrenheit is within the normal range for a newborn and does not indicate an urgent issue. B: A pale pink, rust-colored stain in the diaper could be due to various factors such as diet and is not an immediate concern. C: A heart rate dropping to 120 beats/min in a newborn is generally within the normal range and does not signify a critical issue.

Correct Answer: A

Rationale: The correct answer is A: Place the newborn in skin-to-skin contact with the mother. This is the best nursing action for a newborn experiencing hypothermia because it provides immediate and effective warmth transfer from the mother to the baby. Skin-to-skin contact helps regulate the newborn's body temperature, promotes bonding, and enhances breastfeeding initiation. Choice B is incorrect because while providing a warm blanket is important, skin-to-skin contact with the mother is more effective in quickly raising the newborn's temperature. Choice C is incorrect because administering IV fluids is not the first-line treatment for hypothermia in newborns. Choice D is incorrect because monitoring glucose levels for hypoglycemia is important but addressing the hypothermia should take precedence.