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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?

A.

An indication of a cervical or perineal laceration.

B.

Abnormally excessive lochia rubra flow.

C.

A normal postural discharge of lochia.

D.

Evidence of a possible vaginal hematoma.

Answer and Explanation

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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View Related questions

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","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.

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