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 D
Explanation
Choice D rationale
Using a postpartum depression-screening tool with the client is the first action the nurse should take. This tool helps to assess the severity of the client’s symptoms and determine the appropriate level of care. Early identification and intervention are crucial in managing postpartum depression effectively.
Choice A rationale
Arranging for counseling to help the client cope with the stress of being a parent is important, but it is not the first action. Counseling can be part of the treatment plan after the initial assessment using the screening tool.
Choice B rationale
Reinforcing teaching about ways to increase rest and sleep is beneficial for the client’s overall well-being, but it does not address the immediate need to assess the severity of the client’s depressive symptoms.
Choice C rationale
Requesting a prescription for an antidepressant medication may be necessary, but it should be based on the results of the screening tool and a thorough assessment by a healthcare provider.
Correct Answer is ["A","B","C"]
Explanation
Choice A rationale
Topical creams can help soothe and promote healing of the episiotomy or laceration site.
Choice B rationale
Sitz baths are effective in reducing pain and promoting healing by increasing blood flow to the perineal area.
Choice C rationale
Ice packs help reduce swelling and provide pain relief in the initial 24 hours post-delivery.
Choice D rationale
Tocolytics are not indicated for episiotomy or laceration care as they are used to suppress preterm labor.
Choice E rationale
Doing nothing is not appropriate as it does not address the pain or promote healing.