A nurse is collecting data from a client who is 1 day postpartum.Which of the following findings requires immediate intervention by the nurse?
Decreased urge to void.
Displaced fundus from the midline.
Fundal height below the umbilicus.
Increased urine output.
The Correct Answer is B
Choice A rationale
A decreased urge to void is a common postpartum finding due to the effects of anesthesia and the trauma of childbirth. It does not require immediate intervention unless it leads to bladder distention.
Choice B rationale
A displaced fundus from the midline, especially if it is accompanied by a boggy uterus, indicates uterine atony, which can lead to postpartum hemorrhage. Immediate intervention is required to prevent severe blood loss.
Choice C rationale
A fundal height below the umbilicus is an expected finding 1 day postpartum as the uterus begins to involute. This does not require immediate intervention.
Choice D rationale
Increased urine output is common in the postpartum period as the body eliminates excess fluid accumulated during pregnancy. This is not a cause for immediate concern.
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Correct Answer is B
Explanation
Choice A rationale
Fungal infections typically present with itching, redness, and a thick, white discharge resembling cottage cheese. The yellow-white vaginal drainage described is more consistent with lochia alba, the final stage of lochia, which is a normal postpartum discharge.
Choice B rationale
Lochia alba is the final stage of lochia, occurring around 10 to 14 days postpartum and lasting up to six weeks. It is characterized by a yellowish-white discharge, indicating the end of the postpartum bleeding process.
Choice C rationale
Retained placenta can cause prolonged bleeding and infection, but it is usually associated with heavy bleeding and not a yellow-white discharge. The presence of lochia alba suggests normal postpartum progression.
Choice D rationale
Bacterial infections often present with a foul-smelling discharge, pain, and fever. The yellow-white discharge described is more indicative of lochia alba, a normal postpartum occurrence.
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.