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 A

Explanation

Choice A reason: Position the client on her side is correct, as this is the first action the nurse should take according to the ABCDE priority framework. Late decelerations are symmetrical decreases in the fetal heart rate that begin after the peak of the contraction and return to baseline after the contraction ends, which indicate uteroplacental insufficiency and fetal hypoxia. Positioning the client on her side can improve blood ﬂow and oxygen delivery to the placenta and fetus by relieving pressure on the vena cava and aorta.

Choice B reason: Elevate the client's legs is incorrect, as this is not a priority action for a client who has late decelerations. Elevating the legs can increase venous return and cardiac output, but it can also reduce blood ﬂow and oxygen delivery to the placenta and fetus by compressing the vena cava and aorta.

Choice C reason: Administer oxygen via face mask is incorrect, as this is not the first action the nurse should take, although it is important to do later. Administering oxygen can increase oxygen saturation and delivery to the placenta and fetus, but it does not address the cause of uteroplacental insufficiency or improve blood ﬂow.

Choice D reason: Increase the infusion rate of the IV ﬂuid is incorrect, as this is not the first action the nurse should take, although it may be indicated later. Increasing the infusion rate of IV ﬂuid can expand blood volume and improve placental perfusion, but it does not address the cause of uteroplacental insufficiency or improve blood ﬂow. The nurse should obtain a provider's order before increasing the IV ﬂuid rate.

A. Prepare a warm sitz bath. B. Apply an ice pack to the perineum. C. Place a soft pillow under the client's butocks. D. Position a heating lamp toward the episiotomy.

Correct Answer is B

Explanation

Choice A reason:

A warm sitz bath can promote healing and comfort, but it is not recommended until 24 hr after delivery, as it can increase swelling and bleeding.

Choice B reason:

An ice pack can reduce inﬂammation and pain by causing vasoconstriction and numbing the area. It should be applied for 20 minutes at a time, with a cloth barrier between the skin and the ice.

Choice C reason:

A soft pillow under the client's butocks can increase pressure on the perineum and worsen the pain. The client should be encouraged to lie on her side or sit in a semi-Fowler's position.

Choice D reason:

A heating lamp can dry out the wound and delay healing. It can also cause burns and discomfort. It should be avoided for episiotomy care.

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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 assisting in the care of a client who is in active labor. The nurse notes late decelerations on the fetal monitor tracing. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

A nurse is caring for a client who has unrelieved episiotomy pain 8 hr following delivery. Which of the following actions should the nurse take?

Correct Answer is B

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?