A nurse in a clinic is caring for a client who is antepartum. The client expresses concern about preparing their preschooler for a new sibling.
Which of the following responses should the nurse make?

Choice A rationale

Bladder distention upon palpation indicates urinary retention, meaning the client is unable to void effectively or empty the bladder completely. In the postpartum period, a full bladder can inhibit uterine contraction and increase the risk of postpartum hemorrhage because a distended bladder displaces the uterus, preventing it from clamping down appropriately. The normal range for post-void residual volume is typically less than 100 mL.

Choice B rationale

Not feeling the urge to urinate may be due to decreased bladder sensation following labor and delivery or effects of regional anesthesia, which can lead to urinary retention. Effective voiding is characterized by the ability to sense the urge to void, initiate urination, and empty the bladder, typically passing at least 150 mL per void after catheter removal.

Choice C rationale

Lateral displacement of the uterus is a common sign of a distended bladder. A full bladder pushes the uterus out of its normal midline position, impairing its ability to contract effectively, which increases the risk for uterine atony and subsequent postpartum hemorrhage. The fundus should remain firm and in the midline position after effective voiding.

Choice D rationale

The firming of the fundus with massage indicates that the uterus is contracting, which is essential for preventing postpartum hemorrhage by compressing the blood vessels at the placental site. Effective voiding allows the uterus to remain in its midline position, facilitating proper involution and contractility, which is reflected by a firm fundus.

🧾 Explanation

1. Moderate lochia rubra
   • Normal up to 1–2 weeks postpartum. Not related to mastitis.
2. Temperature 38.4°C
   • Still febrile after 24 hrs of antibiotics → infection not yet controlled.
3. Purulent nipple discharge
   • New finding. Indicates possible breast abscess or worsening mastitis.
4. Hemoglobin 12 g/dL
   • Stable and within normal range. Not relevant to mastitis progression.
5. WBC 35,000/mm³
   • Increased from 28,000 → worsening systemic inflammatory response.
6. Decreased pain
   • Symptomatically better, but this may reflect partial relief from antibiotics/analgesics rather than full resolution. Still, it’s a positive sign.

Summary:

• Improving: Pain relief.
• Unrelated: Lochia rubra, hemoglobin.
• Worsening: Persistent fever, purulent nipple discharge, rising WBC.

This mixed picture suggests partial response but possible complication (breast abscess). The nurse should notify the provider promptly, anticipate breast ultrasound to rule out abscess, and continue close monitoring.