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:
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.
Correct Answer is B
Explanation
Choice B reason:
A fundus that is elevated and displaced from the midline indicates a full bladder, which can interfere with uterine contraction and increase the risk of hemorrhage. The nurse should assist the client to void or catheterize her if necessary.
Choice A reason:
Moderate swelling of the labia is a normal finding after vaginal delivery, and does not indicate a need to urinate. The nurse should apply ice packs and perineal pads to reduce edema and discomfort.
Choice C reason:
Moderate lochia rubra is a normal finding during the first 24 hr postpartum, and does not indicate a need to urinate. The nurse should monitor the amount and color of lochia, and change the perineal pads as needed.
Choice D reason:
A blood pressure of 130/84 mm Hg is within the normal range for a postpartum client, and does not indicate a need to urinate. The nurse should monitor the blood pressure for signs of hypertension or hypotension, which can indicate complications such as preeclampsia or hemorrhage.
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