During a postpartum examination of a client who delivered an 8-pound newborn 6 hours ago, the nurse assesses the following: fundus firm and at the umbilicus, and moderate lochia rubra with a steady trickle of blood noted from the vagina
The nurse realizes that the assessment finding that would necessitate follow-up would be the: 1. Firm fundus.
2. Fundus at the umbilical level.
3. Moderate lochia rubra.
4. Steady trickle of blood.
4. Steady trickle of blood.
Rationale:
The steady trickle of blood could indicate a laceration in the birth canal and should be reported to the health care provider for follow-up. A firm fundus is a desired finding and is considered normal. Six hours after birth, the fundus at the umbilicus would not be a concern. Moderate lochia rubra is considered a normal finding.
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