A nurse is reinforcing discharge instructions for a client.At 4 weeks postpartum, the client should contact the provider for which of the following client findings?
Sore nipple with cracks and fissures.
Scant nonodorous white vaginal discharge.
Uterine cramping during breastfeeding.
Decreased response with sexual activity.
The Correct Answer is A
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.
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Correct Answer is C
Explanation
Choice A rationale
Inserting a urinary catheter is not the first action to take when the fundus is displaced to the right of midline. The displacement is often due to a full bladder, and the client should be encouraged to void first.
Choice B rationale
Massaging the fundus is appropriate if the uterus is boggy, but in this case, the fundus is firm. The displacement is likely due to a full bladder.
Choice C rationale
Having the client urinate is the correct action. A full bladder can displace the uterus and prevent it from contracting properly, which can lead to postpartum hemorrhage.
Choice D rationale
Administering analgesia is not relevant to the issue of a displaced fundus. The priority is to address the cause of the displacement, which is likely a full bladder.
Correct Answer is A
Explanation
Choice A rationale
Ambulation is crucial in preventing thrombophlebitis as it promotes blood circulation and prevents blood stasis, which can lead to clot formation.
Choice B rationale
Warm, moist soaks can provide comfort but do not significantly contribute to preventing thrombophlebitis.
Choice C rationale
Bed rest increases the risk of thrombophlebitis due to decreased circulation and blood stasis.
Choice D rationale
Placing pillows under the knees can impede blood flow and increase the risk of clot formation.