During ambulation to the bathroom, a postpartum client experiences a gush of dark red blood that soon stops.On data collection, a nurse finds the uterus to be firm, midline, and at the level of the umbilicus.Which of the following findings should the nurse interpret this data as being?
An indication of a cervical or perineal laceration.
Abnormally excessive lochia rubra flow.
A normal postural discharge of lochia.
Evidence of a possible vaginal hematoma.
The Correct Answer is C
Choice A rationale
A cervical or perineal laceration would typically result in continuous bleeding rather than a gush that stops. The uterus would also not be firm and midline if there were a significant laceration.
Choice B rationale
Abnormally excessive lochia rubra flow would be continuous and not stop after a gush. The uterus being firm and midline indicates that the bleeding is not excessive.
Choice C rationale
A normal postural discharge of lochia occurs when pooled blood in the vagina is expelled upon standing or changing position. This is common and expected in the postpartum period.
Choice D rationale
A vaginal hematoma would present with localized pain and swelling, and the bleeding would not stop suddenly. The uterus being firm and midline also indicates that a hematoma is unlikely.
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Correct Answer is C
Explanation
Choice A rationale
A cervical or perineal laceration would typically result in continuous bleeding rather than a gush that stops. The uterus would also not be firm and midline if there were a significant laceration.
Choice B rationale
Abnormally excessive lochia rubra flow would be continuous and not stop after a gush. The uterus being firm and midline indicates that the bleeding is not excessive.
Choice C rationale
A normal postural discharge of lochia occurs when pooled blood in the vagina is expelled upon standing or changing position. This is common and expected in the postpartum period.
Choice D rationale
A vaginal hematoma would present with localized pain and swelling, and the bleeding would not stop suddenly. The uterus being firm and midline also indicates that a hematoma is unlikely.
Correct Answer is D
Explanation
Choice D rationale
Applying an ice pack to the perineum is the recommended action for unrelieved episiotomy pain within the first 24 hours following delivery. Ice helps reduce swelling and provides pain relief.
Choice A rationale
Placing a soft pillow under the client’s buttocks is not effective and can increase pressure and swelling on the perineal area, worsening the pain.
Choice B rationale
Positioning a heating lamp toward the episiotomy is not recommended as it can increase the risk of burns and does not effectively reduce swelling.
Choice C rationale
Preparing a warm sitz bath can be beneficial after the first 24 hours but is not the initial action for unrelieved pain within the first 8 hours.