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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?

A.

Urinary tract infections are associated with increased lochia.

B.

Lochia can pool in the vagina while you lie in bed.

C.

You might have retained fragments of your placenta.

D.

The amount of lochia increases during the postpartum period.

Answer and Explanation

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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View Related questions

Correct Answer is A

Explanation

Choice A rationale

Sore nipples with cracks and fissures can indicate an infection or improper breastfeeding technique, requiring medical attention.

Choice B rationale

Scant nonodorous white vaginal discharge is normal postpartum and does not require contacting the provider.

Choice C rationale

Uterine cramping during breastfeeding is a normal physiological response due to oxytocin release.

Choice D rationale

Decreased response with sexual activity can be normal postpartum and does not necessarily require immediate medical attention.

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.

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