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?
Urinary tract infections are associated with increased lochia.
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.
The Correct Answer is B
Choice A rationale
Urinary tract infections (UTIs) are not typically associated with increased lochia. UTIs usually present with symptoms such as burning during urination, frequent urination, and lower abdominal pain.
Choice B rationale
Lochia can pool in the vagina while lying in bed, leading to a larger amount being expelled upon standing. This is a normal occurrence and not a cause for concern.
Choice C rationale
Retained fragments of the placenta can cause heavy bleeding and infection, but the sudden expulsion of a large amount of lochia upon standing is more likely due to pooling rather than retained placenta.
Choice D rationale
The amount of lochia typically decreases over time during the postpartum period. An increase in lochia is not expected and should be evaluated for other causes.
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Correct Answer is C
Explanation
Choice A rationale
Within 2 days after delivery is not the typical timeframe for breast milk to come in. Colostrum, the first milk, is produced immediately after birth, but mature milk usually comes in a few days later.
Choice B rationale
In about 10 days after delivery is too late for the onset of mature breast milk. Most women experience their milk coming in within the first week postpartum.
Choice C rationale
In 3 to 5 days after delivery is the correct response. This is the typical timeframe for the transition from colostrum to mature milk. During this period, the breasts may feel fuller and heavier as milk production increases.
Choice D rationale
In 6 to 8 days after delivery is later than the usual timeframe for breast milk to come in. While there can be some variation, most women experience their milk coming in within 3 to 5 days postpartum.
Correct Answer is B
Explanation
Choice A rationale
Massaging the area is not recommended as it can dislodge a clot and cause it to travel to the lungs, leading to a pulmonary embolism. This can be life-threatening and should be avoided.
Choice B rationale
Elevating the leg helps to reduce swelling and pain by promoting venous return. This is a standard intervention for managing symptoms of deep vein thrombosis (DVT) and helps prevent further complications.
Choice C rationale
Applying cold compresses is not effective for DVT. Cold compresses are generally used to reduce inflammation and pain in acute injuries, but they do not address the underlying issue of a blood clot.
Choice D rationale
Flexing the knee while resting can increase the risk of clot dislodgement and is not recommended. Keeping the leg straight and elevated is a safer approach to managing DVT symptoms.