A nurse is assisting with the monitoring of a client who is in labor.
Which of the following findings should the nurse report to the provider?

Choice A rationale:

Lochia pooling: When a woman lies in bed, gravity causes lochia to pool in the vagina. This can result in a larger amount of

lochia being expelled when she stands up or moves around.

Reassurance: Explaining this physiological process to the client can help to reassure her that the sudden increase in lochia is

normal and not a cause for alarm.

Validation: The nurse should validate the client's feelings of concern, as it is understandable for a new mother to be anxious

about any changes in her body after childbirth.

Education: The nurse should also provide education about lochia, including its typical characteristics, duration, and expected

changes. This can help the client to anticipate and understand her postpartum experience.

Choice B rationale:

Retained placenta: While retained fragments of the placenta can cause increased lochia, this is not the most common

this possibility, especially before further assessment.

Assessment and intervention: If there is a concern for retained placenta, the nurse would conduct a thorough assessment,

including fundal height, uterine tone, and lochia characteristics. Further interventions, such as ultrasound or manual

exploration of the uterus, may be necessary.

Choice C rationale:

Urinary tract infections (UTIs): UTIs can sometimes cause an increase in lochia, but they are not typically associated with a

sudden, large gush of lochia upon standing. Other symptoms of a UTI, such as burning with urination, urgency, or frequency,

would likely be present as well.

Assessment and intervention: If a UTI is suspected, the nurse would assess for urinary symptoms and collect a urine sample

for analysis. Antibiotic treatment would be initiated if a UTI is confirmed.

Choice D rationale:

Lochia progression: The amount of lochia generally decreases over time during the postpartum period. It is heaviest in the first

few days after delivery and gradually tapers off over the course of several weeks.

Inconsistency with presentation: While this statement is true, it does not directly address the client's concern about a sudden

Choice A rationale:

Pushing continuously throughout the entire contraction can lead to maternal exhaustion and may not be the most effective way to progress labor. It’s important for the mother to conserve her energy and work with her body’s natural rhythms.

Choice B rationale:

Taking a deep, cleansing breath before and after each contraction can help the mother manage pain and keep her energy up.

This technique is often recommended because it allows the mother to rest briefly and gather strength for the next contraction.

Choice C rationale:

While it’s important for the nurse to monitor contractions and provide guidance, the urge to push is a natural response that

can vary among individuals. Telling the mother when to push according to contractions may not align with her body’s natural

instincts.

Choice D rationale:

Holding one’s breath and pushing while someone counts to ten is an outdated practice. This method can cause unnecessary

strain and doesn’t take into account the individual rhythms and responses of the mother’s body.