The nurse assesses a postpartum patient as having moderate lochia rubra with clots on her second postpartum day. Which of the following interventions would be appropriate?

Assess the fundus and bladder status


• Lochia rubra is a postpartum vaginal discharge consisting almost entirely of blood. There are often small particles of deciduas and mucus during the first 3 postpartum days. This is expected.

• There is no complication or any signs of postpartum hemorrhage.

• During birth, the fetal head exerts pressure on the bladder and urethra as it passes on the bladder’s underside. This pressure may leave the bladder with a transient loss of tone. To prevent permanent damage to the bladder from over-distention, assess the woman’s abdomen frequently.

• To assess involution process (the shrinking of the uterus after the birth), the nurse should palpate the fundus to see if it is firm and well-contracted.

• Incorrect: Methergine should not be given because the woman is in her second postpartum day and has a normal lochia as expected.

• Incorrect: The other intervention choices are inappropriate because the woman is not suffering from blood loss.

Visit our website for other NCLEX topics now!