The nurse is assessing her patient, who is 1 day postpartum. The nurse notes that the fundus is firm and at midline, the lochia is moderate in amount, and the presence of rubra with two dime-sized clots is on her peri-pad. What should the nurse determine from these assessment findings?

Correct Answer: A

Rationale: The correct answer is A, as the assessment findings described are normal for a patient who is 1 day postpartum. A firm and midline fundus indicates proper uterine involution. Moderate lochia is expected at this stage, and the presence of small clots is normal. The overall picture suggests the normal process of healing after childbirth. Choice B is incorrect because the assessment findings do not indicate signs of infection such as foul-smelling lochia, fever, or elevated white blood cell count. Choice C is incorrect as there are no abnormal findings that would warrant immediate notification of the physician. Choice D is incorrect as there is no indication from the assessment findings that the patient needs to increase her fluid intake; the findings are within the expected range for a patient 1 day postpartum.

Correct Answer: C

Rationale: The correct answer is C because washing hands before and after performing peri-care is essential to prevent the spread of infections. Before touching the perineal area, proper hand hygiene reduces the risk of introducing harmful bacteria. After caring for the perineum, washing hands again prevents transferring any bacteria to other parts of the body. This demonstrates understanding of infection prevention. Choice A is incorrect because applying the peri-pad from back to front can introduce bacteria from the rectal area to the vaginal area, increasing the risk of infection. Choice B is incorrect because the frequency of performing peri-care depends on individual needs and hygiene practices, so stating a fixed number of times is not indicative of understanding. Choice D is incorrect because mixing tap water and hydrogen peroxide in the peri-bottle is not a recommended practice for peri-care and may cause irritation or disrupt the natural balance of the vaginal flora.

Correct Answer: D

Rationale: Step 1: Palpating the uterus 12 hours after delivery is to assess for proper involution. Step 2: Placing a hand above the symphysis pubis helps to prevent uterine inversion. Step 3: Uterine inversion is a rare but serious complication post-delivery. Step 4: By supporting the uterus, the nurse prevents the risk of inversion. Summary: A is incorrect as palpation doesn't prevent prolapse. B is incorrect as some uterine movement is normal. C is incorrect as palpation doesn't prevent hemorrhage at this stage.

Correct Answer: B

Rationale: The correct answer is B: WBC laboratory level of 30,000/mm a few hours after delivery. Postpartum, a temporary increase in white blood cells (WBCs) is normal due to the body's response to delivery and potential inflammation. This increase is known as leukocytosis and helps the body combat potential infections. The other choices are incorrect because: A is more related to hypovolemia than to cardiovascular changes. C is incorrect as clotting factors increase postpartum to reduce the risk of hemorrhage. D is incorrect as a hemoglobin level less than 11 g/dL postpartum may indicate anemia, not normalcy.

Correct Answer: D

Rationale: The correct answer is D: General soreness. Postpartum pain assessment typically focuses on specific sources such as uterine contractions, perineal trauma, and breast engorgement. General soreness is too vague and does not provide specific information for targeted intervention. By ruling out general soreness, the nurse can prioritize assessment and management of more specific sources of pain to provide appropriate care for the postpartum patient.