A nurse on the labor and delivery unit is planning care for a client who has human immunodeficiency virus (HIV). Which of the following is an appropriate action for the nurse to take following the birth of the newborn?

Bladder distention is a common postpartum complication that can occur due to decreased bladder sensation, perineal edema, trauma, or pain after vaginal birth. Bladder distention can interfere with uterine contraction and involution, leading to increased bleeding and risk of infection. Therefore, it is important to assess and manage bladder distention promptly and effectively in postpartum clients.
The first action the nurse should take for a client who has bladder distention is to assist the client to the bathroom and encourage voiding. This is the least invasive and most natural way to empty the bladder and relieve the distention. The nurse should provide privacy, comfort, and support to the client, and help with perineal care after voiding. The nurse should also measure the urine output and monitor for signs of urinary retention or infection, such as dribbling, frequency, urgency, dysuria, hematuria, or foul-smelling urine.

b) Inserting a urinary catheter is not the first action the nurse should take for a client who has bladder distention. A urinary catheter is an invasive procedure that can introduce infection, trauma, or irritation to the urinary tract. It should be used only as a last resort when other methods of bladder emptying have failed or are contraindicated. The nurse should obtain a provider's order before inserting a urinary catheter and follow strict aseptic technique.
c) Offering the client a sitz bath is not the first action the nurse should take for a client who has bladder distention. A sitz bath is a warm water bath that covers only the hips and buttocks. It can provide comfort and promote healing for clients who have perineal lacerations, episiotomies, or hemorrhoids after vaginal birth. However, it does not directly address bladder distention or facilitate voiding. It may also increase the risk of infection or bleeding if done too soon or too frequently after delivery.
d) Pouring warm water over the client's perineum is not the first action the nurse should take for a client who has bladder distention. Pouring warm water over the perineum can help with perineal care and hygiene after vaginal birth. It can also stimulate voiding by creating a relaxing effect on the pelvic floor muscles. However, it does not ensure complete bladder emptying or relieve bladder distention. It may also cause discomfort or irritation if the water temperature or pressure is too high.

When providing postpartum care teaching to a client, the nurse should include accurate and appropriate information. Option b) "You can expect your breasts to be firm and tender 3 to 5 days after delivery" is a correct statement.

Breast engorgement is a common occurrence around the third to fifth day after delivery as the breasts transition from producing colostrum to mature milk. This can cause the breasts to become firm, swollen, and tender. It is important for the client to be aware of this normal physiological change and to understand how to manage it effectively, such as by applying warm or cold compresses, expressing milk, and ensuring proper breastfeeding techniques.

Option a) "Your bleeding will remain bright red for the next 6 to 8 weeks" is an incorrect statement. After childbirth, the bleeding, called lochia, typically progresses from bright red to a pinkish color and then to a yellowish-white discharge. The duration and characteristics of lochia can vary for each individual, but it generally resolves within a few weeks.

Option c) "You don't need to use birth control if you are exclusively breastfeeding" is an incorrect statement. While breastfeeding can provide some natural contraception, it is not foolproof, and the client can still ovulate and become pregnant. It is important for the client to discuss and choose a suitable method of contraception with her healthcare provider.

Option d) "You should begin performing Kegel exercises 6 to 7 weeks after delivery" is an incorrect statement. Kegel exercises, which strengthen the pelvic floor muscles, can be started as early as the immediate postpartum period and are beneficial for promoting bladder and bowel control, as well as aiding in postpartum recovery. The client can begin performing Kegel exercises soon after delivery, as guided by her healthcare provider.