A nurse is assessing a client postpartum.Which of the following findings should alert the nurse to the client's need to urinate?

Choice A rationale

Swelling of the labia postpartum can be a common occurrence due to trauma during delivery and does not specifically indicate the need to urinate. The swelling usually subsides with time and proper postpartum care.

Choice B rationale

A fundus positioned three fingerbreadths above the umbilicus can indicate a full bladder. The bladder's distension prevents the uterus from contracting properly, which can lead to postpartum hemorrhage and other complications, hence the need for the client to urinate.

Choice C rationale

Moderate lochia rubra is a normal finding in the postpartum period and does not specifically indicate the need to urinate. Lochia changes in color and amount over the postpartum weeks as the uterus heals.

Choice D rationale

Swelling of the ankles and feet, or edema, is common postpartum due to the body's adjustment to changes in blood volume and fluid shifts. It does not directly indicate the need to urinate.

Choice A rationale

Timing pain medication to avoid affecting the baby is important, but discussing pain management options provides a comprehensive approach.

Choice B rationale

Informing that all medications are found in breast milk can cause unnecessary worry without offering a solution.

Choice C rationale

Allowing the option to avoid pain medication doesn't address the need for effective pain management.

Choice D rationale

Discussing pain management options ensures the mother is aware of safe choices that won't harm breastfeeding.