Maternity Nursing: Postpartum Q 52
When performing a PP assessment on a client, the nurse notes the presence of clots in the lochia. The nurse examines the clots and notes that they are larger than 1 cm. Which of the following nursing actions is most appropriate?
A. Document the findings.
B. Notify the physician.
C. Reassess the client in 2 hours.
D. Encourage increased intake of fluids.
Correct Answer: B. Notify the physician.
Normally, one may find a few small clots in the first 1 to 2 days after birth from pooling of blood in the vagina. Clots larger than 1 cm are considered abnormal. The cause of these clots, such as uterine atony or retained placental fragments, needs to be determined and treated to prevent further blood loss.
Option A: Although the findings would be documented, the most appropriate action is to notify the physician. Early postpartum hemorrhage is described as that occurring within the first 24 hours after delivery. Late postpartum hemorrhage most frequently occurs 1-2 weeks after delivery but may occur up to 6 weeks postpartum.
Option C: The persistence of red lochia beyond one week might be an indicator of uterine subinvolution. The presence of an offensive odor or large pieces of tissue or blood clots in lochia or the absence of lochia might be a sign of infection.
Option D: The most common cause of immediate postpartum hemorrhage is atony; therefore uterotonic agents should be readily available for quick access and prompt administration in order to control bleeding.