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
Within 2 days after delivery is not the typical timeframe for breast milk to come in. Colostrum, the first milk, is produced immediately after birth, but mature milk usually comes in a few days later.
Choice B rationale
In about 10 days after delivery is too late for the onset of mature breast milk. Most women experience their milk coming in within the first week postpartum.
Choice C rationale
In 3 to 5 days after delivery is the correct response. This is the typical timeframe for the transition from colostrum to mature milk. During this period, the breasts may feel fuller and heavier as milk production increases.
Choice D rationale
In 6 to 8 days after delivery is later than the usual timeframe for breast milk to come in. While there can be some variation, most women experience their milk coming in within 3 to 5 days postpartum.
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.