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 A
Explanation
Choice A rationale
Measuring leg circumferences is a crucial intervention for a client with thrombophlebitis. This helps in monitoring for any increase in swelling, which can indicate worsening of the condition or the development of complications such as deep vein thrombosis (DVT). Regular measurement allows for early detection and timely intervention.
Choice B rationale
Massaging the affected extremity is contraindicated in clients with thrombophlebitis. Massage can dislodge a thrombus, leading to a potentially life-threatening pulmonary embolism. Therefore, this intervention should be avoided.
Choice C rationale
Applying cold compresses to the affected extremity is not recommended for thrombophlebitis. Cold compresses can cause vasoconstriction, which may worsen the condition by reducing blood flow and increasing the risk of clot formation.
Choice D rationale
Allowing the client to ambulate is not advisable in the acute phase of thrombophlebitis. Ambulation can increase the risk of thrombus dislodgement and subsequent pulmonary embolism. Bed rest with the affected limb elevated is usually recommended until the acute phase resolves.
Correct Answer is C
Explanation
Choice A rationale
While sharing personal experiences can sometimes be comforting, it may not always be appropriate or helpful in a professional setting. The focus should be on the patient’s needs and feelings.
Choice B rationale
Calling for a chaplain can be supportive, but it is important to first offer the parents the opportunity to hold their baby and spend time with them, which can be an important part of the grieving process.
Choice C rationale
Allowing the parents to hold their baby for as long as they want provides them with the opportunity to say goodbye and can be a crucial part of the grieving process. It helps them to acknowledge their loss and begin to process their emotions.
Choice D rationale
Telling the parents that the loss is for the best is not supportive and can be hurtful. It is important to validate their feelings and provide compassionate care during this difficult time.