A nurse is assisting in the care of a client on a postpartum unit. The client had an uncomplicated vaginal delivery 24 hours ago. Which of the following data collection findings should the nurse report to the primary RN immediately?

Moderate lochia rubra on the pad

Nipple tenderness with breastfeeding

Hemorrhoids on the rectal area

Calf edematous and tender

Answer and Explanation

The Correct Answer is D

A. Moderate lochia rubra on the pad: Moderate lochia 24 hours postpartum is considered a normal finding as the uterus continues to shed the lining. It typically appears bright red and gradually decreases over the following days, so it does not require immediate reporting.

B. Nipple tenderness with breastfeeding: Nipple tenderness is common in the early postpartum period due to breastfeeding, especially if the latch is not optimal. While it should be addressed to prevent complications, it is not an urgent finding requiring immediate reporting.

C. Hemorrhoids on the rectal area: Hemorrhoids are a frequent postpartum occurrence, often resulting from vaginal delivery or straining during labor. They are uncomfortable but not emergent, so they do not need immediate reporting.

D. Calf edematous and tender: A calf that is swollen, edematous, and tender may indicate a deep vein thrombosis (DVT), which is a potentially life-threatening postpartum complication. This finding requires immediate reporting to the primary RN for timely assessment and intervention.

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Correct Answer is B

Explanation

A. Explain to the client that anxiety causes physical manifestations: While educating the client about the connection between anxiety and physical symptoms is important, it does not immediately reduce the acute distress the client is experiencing.

B. Minimize environmental stimuli in the client's surroundings: Reducing environmental stimuli helps decrease sensory overload and can lower acute anxiety levels. This intervention addresses the client’s immediate physiological and psychological distress, making it the priority action.

C. Explore behaviors that have helped to reduce the client's anxiety in the past: Identifying coping strategies is useful for long-term management, but it does not provide immediate relief during an acute episode of anxiety.

D. Administer an anti-anxiety medication: Pharmacological intervention may be necessary, but non-pharmacological measures to reduce stimuli should be implemented first to provide rapid relief and create a calm environment before medication administration.

A. Determine the client's pattern for voiding B. Discourage intake of carbonated beverages. C. Offer toileting opportunities every 1 to 2 hr D. Assist the client with relation techniques.

Correct Answer is A

Explanation

A. Determine the client's pattern for voiding: Assessing the client’s typical voiding schedule provides essential baseline data to individualize the bladder training program. Understanding frequency, timing, and triggers allows the nurse to develop an effective and structured plan for toileting.

B. Discourage intake of carbonated beverages: Limiting bladder irritants can support continence but is secondary to first assessing the client’s voiding patterns. Dietary modifications alone will not optimize bladder training without an individualized schedule.

C. Offer toileting opportunities every 1 to 2 hr: Regular toileting supports bladder control, but it should be based on the client’s identified voiding pattern. Implementing a schedule before assessment may be inefficient or disruptive.

D. Assist the client with relaxation techniques: Relaxation can help facilitate voiding, but it is an adjunct intervention. Determining the voiding pattern first ensures that relaxation strategies are applied at appropriate times to maximize effectiveness.

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A nurse is assisting in the care of a client on a postpartum unit. The client had an uncomplicated vaginal delivery 24 hours ago. Which of the following data collection findings should the nurse report to the primary RN immediately?

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