A nurse is assisting a client out of bed for the first time since delivery. The client becomes frightened when she passes a large amount of lochia.
Which of the following responses should the nurse make?

'Lochia can pool in the vagina while you lie in bed.'

'You might have retained fragments of your placenta.'

'The amount of lochia increases during the postpartum period.'

'Urinary tract infections are associated with increased lochia.'

Answer and Explanation

The Correct Answer is A

Choice A reason: This is the most appropriate response because it reassures the client that the amount of lochia she passed is normal and expected after lying down for a long time. Lochia is the vaginal discharge that occurs after childbirth, consisting of blood, mucus, and uterine tissue. It usually decreases in amount and changes in color over time, from red to pink to brown to yellow.

Choice B reason: This is an incorrect response because it implies that the client has a complication that requires further evaluation. Retained placental fragments can cause excessive bleeding, infection, and uterine atony. The nurse should not alarm the client with this possibility without evidence.

Choice C reason: This is an incorrect response because it contradicts the normal patern of lochia. The amount of lochia usually decreases during the postpartum period, not increases. If the client has an increase in lochia, it could indicate a problem such as infection, subinvolution, or hemorrhage.

Choice D reason: This is an incorrect response because it confuses the client with unrelated information. Urinary tract infections are not associated with increased lochia. They are caused by bacteria entering the urinary tract and can cause symptoms such as dysuria, frequency, urgency, and hematuria. The nurse should not suggest that the client has a urinary tract infection without evidence.

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Correct Answer is B

Explanation

Choice A reason:

A urinary output of 2,000 mL/12 hr is normal for a postpartum client, as the body eliminates excess ﬂuid accumulated during pregnancy.

Choice B reason:

A temperature of 100.4 F for two days indicates a possible infection, such as endometritis or mastitis, and requires further evaluation and treatment.

Choice C reason:

Chills shortly following delivery are common and benign and are caused by hormonal changes and ﬂuid shifts.

Choice D reason:

A fundus at the umbilicus level is expected for a postpartum client and indicates that the uterus is involuting properly.

A. Place the client in a lateral position. B. Notify the provider. C. Increase IV ﬂuid rate. D. Elevate the legs.

Correct Answer is A

Explanation

Choice A reason:
Placing the client in a lateral position is the first action the nurse should take, as it can improve maternal and fetal circulation by relieving pressure on the inferior vena cava. The client's blood pressure is low, which can indicate hypotension due to epidural anesthesia or supine hypotension syndrome.

Choice B reason:
Notifying the provider is an important action, as it can facilitate further interventions and monitoring for the client and the fetus. However, this is not the first action the nurse should take, as it does not address the immediate problem of hypotension.

Choice C reason:
Increasing IV ﬂuid rate is an important action, as it can expand blood volume and increase blood pressure. However, this is not the first action the nurse should take, as it may not be eﬀective if the client is in a supine position.

Choice D reason:
Elevating the legs is an important action, as it can enhance venous return and increase blood pressure. However, this is not the first action the nurse should take, as it may worsen supine hypotension syndrome by increasing pressure on the inferior vena cava.

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A nurse is assisting a client out of bed for the first time since delivery. The client becomes frightened when she passes a large amount of lochia. Which of the following responses should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who is postpartum. Which of the following findings should alert the nurse to the possibility of a postpartum complication?

Correct Answer is B

Explanation

A nurse is assisting with the care of a client who had an epidural anesthesia block during the early stages of labor. The client's blood pressure is 80/40 mm Hg and the fetal heart recording is 140/min. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

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A nurse is assisting a client out of bed for the first time since delivery. The client becomes frightened when she passes a large amount of lochia.
Which of the following responses should the nurse make?