The nurse assesses the postpartum client to have moderate lochia rubra with clots. Which of the following nursing interventions would be appropriate?
1. Assess fundus and bladder status.
2. Catheterize the client.
3. Administer Methergine IM per order.
4. Contact the physician immediately.
1
Rationale:
1. Assess the fundus and bladder status first. Moderate lochia, even with clots, might be due to the client's supine position for several hours, or to other factors.
2. Catheterizing the client might be an intervention if the bladder is full and the client is unable to void, but it is not the initial intervention.
3. It is not necessary to administer Methergine IM per order; the situation does not warrant this intervention.
4. It is not necessary to contact the physician immediately; the situation does not warrant this intervention.
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