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:
Auscultating the client's abdomen is the first action the nurse should take, as it can assess the return of bowel function after surgery. The nurse should listen for bowel sounds in all four quadrants, and note their frequency and quality.

Oﬀering clear liquids is an important action, as it can provide hydration and nutrition for the client. However, this is not the first action the nurse should take, as it may cause nausea and vomiting if the client's bowel function has not returned.

Choice C reason:
Checking the client's chart for a diet prescription is an important action, as it can ensure that the client follows the provider's orders and does not consume anything contraindicated. However, this is not the first action the nurse should take, as it does not address the client's hunger or bowel function.

Choice D reason:
Giving the client soda crackers is an important action, as it can provide a bland and easily digestible food for the client. However, this is not the first action the nurse should take, as it may be too solid for the client's stomach if her bowel function has not returned.

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

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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?