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.'
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
Feeling for a full bladder is not the first action the nurse should take, although it is important to assess for bladder distension and urinary retention in postpartum clients. A full bladder can displace the uterus and increase the risk of uterine atony and hemorrhage.
Choice B reason:
Checking the client's fundus is the first action the nurse should take, as it can indicate the tone and position of the uterus. A firm and midline fundus indicates adequate uterine contraction and prevents excessive bleeding. A boggy or deviated fundus indicates uterine atony or retained placental fragments, which can cause hemorrhage.
Choice C reason:
Measuring the client's vital signs is not the first action the nurse should take, although it is important to monitor for signs of shock and infection in postpartum clients. Vital signs can be affected by various factors and do not provide a direct assessment of uterine status.
Choice D reason:
Requesting the provider perform a vaginal examination is not the first action the nurse should take, as it can introduce infection and trauma to the perineum. A vaginal examination is only indicated if there is suspicion of cervical or vaginal lacerations or retained placenta.
Correct Answer is C
Explanation
Choice A reason: Encourage the client to nurse more frequently so her milk will come in is incorrect, as this action is not related to the data collected by the nurse. The nurse notes that the client's breasts are soft, which indicates that the milk has not come in yet. This is normal and expected for a client who is 14 hr postpartum, as milk production usually begins around 72 to 96 hr after birth. The nurse should encourage the client to nurse frequently and effectively to stimulate milk production and prevent engorgement.
Choice B reason: Increase IV fluids is incorrect, as this action is not indicated by the data collected by the nurse. The nurse notes that the client's vital signs are within normal limits, except for a slight temperature elevation. Increasing 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.
Choice C reason: Ask the client to empty her bladder is correct, as this action is indicated by the data collected by the nurse. The nurse notes that the client's fundus is firm but slightly deviated to the right, which suggests bladder distension. A full bladder can interfere with uterine contraction and involution and increase the risk of hemorrhage and infection. The nurse should assist the client to empty their bladder and reassess the fundal position.
Choice D reason: Report the client's temperature elevation is incorrect, as this action is not necessary for a slight temperature elevation in a postpartum client. The nurse notes that the client's temperature is 37.7° C (100° F), which is slightly above normal but within the range of expected findings for a postpartum client. A mild temperature elevation in the first 24 hr after birth can be due to dehydration, exertion, or hormonal changes and does not indicate infection. The nurse should encourage oral fluid intake and monitor the temperature every 4 hr.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today