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 B reason:
Uterine atony is the failure of the uterus to contract and retract after delivery, which can lead to excessive bleeding and hemorrhage. The client is at risk for uterine atony due to delivering a large newborn, which can overstretch the uterine muscles and reduce their tone.

Choice A reason:
Puerperal infection is an infection of the reproductive tract that occurs within six weeks after delivery. The client is not at increased risk for puerperal infection due to delivering a large newborn, unless there are other factors such as prolonged labor, multiple vaginal exams, or episiotomy.

Choice C reason:
Thrombophlebitis is an inﬂammation of a vein with a blood clot formation. The client is not at increased risk for thrombophlebitis due to delivering a large newborn, unless there are other factors such as immobility, dehydration, or trauma.

Choice D reason:
Retained placental fragments are pieces of the placenta that remain in the uterus after delivery, which can cause bleeding and infection. The client is not at increased risk for retained placental fragments due to delivering a large newborn, unless there are other factors such as abnormal placental atachment, manual removal, or incomplete separation.

A. Perform fundal massage. B. Assist the client to ambulate. C. Check for blood under the client's butock. D. Increase the rate of the IV ﬂuids.

Correct Answer is B

Explanation

Choice A reason: Perform fundal massage is incorrect, as this action is not indicated for a client who has a firm and midline fundus. Fundal massage is used to stimulate uterine contraction and prevent hemorrhage in clients who have a boggy or deviated fundus.

Choice B reason: Assist the client to ambulate is correct, as this action can promote lochia drainage and prevent pooling of blood in the vagina. The nurse should encourage the client to ambulate early and frequently after birth, as long as there are no contraindications. The nurse should also monitor the client for signs of orthostatic hypotension and provide assistance as needed.

Choice C reason: Check for blood under the client's butock is incorrect, as this action is not necessary for a client who has a small amount of lochia rubra on the perineal pad. Lochia rubra is normal and expected in the first few days after birth, and it indicates that the placental site is healing. The nurse should check for blood under the butock only if there is suspicion of excessive bleeding or concealed hemorrhage.

Choice D reason: Increase the rate of the IV ﬂuids is incorrect, as this action is not indicated for a client who has a small amount of lochia rubra on the perineal pad. Increasing the rate of IV ﬂuids can cause ﬂuid overload and electrolyte imbalance in the client. The nurse should maintain the IV ﬂuids at the prescribed rate and monitor the client's intake and output.

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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 caring for a postpartum client following a vaginal birth of a newborn weighing 4252 g (9 lb 6 oz). The nurse should identify that this client is at risk for which of the following postpartum complications?

Correct Answer is B

Explanation

A nurse is caring for a client who is 4 hr postpartum. The nurse finds a small amount of lochia rubra on the client's perineal pad. The fundus is midline and firm at the umbilicus. 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?