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 D
Explanation
Choice D rationale
Assisting the client to void is the first action the nurse should take. A full bladder can cause the fundus to deviate to the right and become boggy. Voiding helps the uterus contract and return to its normal position.
Choice A rationale
Inserting an indwelling urinary catheter may be necessary if the client is unable to void, but it is not the first action.
Choice B rationale
Administering methylergometrine to the client is not the first action. This medication stimulates uterine contractions and can help reduce postpartum bleeding, but the initial step is to address the full bladder.
Choice C rationale
Obtaining a stat hemoglobin level is important if there is a concern for significant blood loss, but it is not the first action.
Correct Answer is C
Explanation
Choice A rationale
It is incorrect to say that birth control is not needed for at least six months. Ovulation can occur much sooner, and contraception should be discussed early.
Choice B rationale
Most people do not need birth control for three months is also incorrect. Ovulation can resume as early as three weeks postpartum.
Choice C rationale
Ovulation can occur within 27 days postpartum, making it important to discuss contraception early to prevent unintended pregnancies.
Choice D rationale
Agreeing with the statement is incorrect and can lead to misinformation. It is important to provide accurate information about postpartum ovulation and contraception.