A nurse is caring for a client who has heart failure and is taking furosemide.
Which of the following statements by the client indicates a need for the nurse to intervene?

A client who is 1 day postpartum and has not voided in 8 hr. This client is at risk of urinary retention, bladder distension, and infection due to the effects of epidural anesthesia, perineal trauma, and fluid shifts after delivery. The nurse should assess the client’s bladder and catheterize if necessary.

Choice A is wrong because a client who is 2 days postpartum and whose fundus is 2 to 4 cm below the umbilicus is showing a normal finding.

The fundus should descend about 1 to 2 cm per day after delivery and be nonpalpable by day 10.

Choice B is wrong because a client who is 3 days postpartum and has not had a bowel movement since prior to admission is not uncommon.

Constipation is a common problem after delivery due to decreased peristalsis, dehydration, and fear of pain.

The nurse should encourage fluid intake, fiber intake, and early ambulation to promote bowel function.

Choice C is wrong because a client who is 4 days postpartum and has lochia serosa is also showing a normal finding.

Lochia serosa is the pinkish-brown discharge that occurs from day 4 to 10 after delivery.

It consists of old blood, serum, leukocytes, and tissue debris.

Keep your environment well ventilated. This can help reduce nausea and vomiting by eliminating odors that might trigger them.

Some additional explanations are:

Choice B is wrong because eating three large meals each day can increase nausea and vomiting by overloading the stomach. It is better to eat small, frequent meals and avoid spicy, greasy, or strong-smelling foods.

Choice C is wrong because restricting intake of high-carbohydrate foods can lead to ketosis, which can worsen nausea and vomiting. High-carbohydrate foods can also help settle the stomach and provide energy.

Choice D is wrong because brushing your teeth immediately after eating can stimulate the gag reflex and cause nausea and vomiting. It is better to rinse your mouth with water or mouthwash after eating and brush your teeth at least an hour later.

Normal ranges for nausea and vomiting in pregnancy are:

• Nausea and vomiting usually start around 6 weeks of gestation and peak around 9 weeks. They usually subside by 16 to 20 weeks, but some women may experience them throughout pregnancy.
• Nausea and vomiting are considered mild if they do not interfere with daily activities or nutrition. They are considered moderate if they cause some difficulty with daily activities or nutrition. They are considered severe if they prevent adequate intake of fluids and nutrients, cause weight loss, dehydration, electrolyte imbalance, or ketonuria.
• Nausea and vomiting that are severe or persist beyond 20 weeks of gestation may indicate a complication such as hyperemesis gravidarum, molar pregnancy, multiple gestation, or infection.