A nurse is assessing a client who is 8 hours postpartum and multiparous.
Which of the following findings should alert the nurse to the client’s need to urinate?

 

Choice A rationale:

Placing a soft pillow under the client's buttocks is not recommended for episiotomy pain relief. It can actually increase pain by placing pressure on the perineum and impeding blood flow to the area. This can hinder healing and prolong discomfort.

Additionally, it can separate the buttocks, potentially decreasing venous return and further exacerbating pain.

Choice C rationale:

Positioning a heating lamp toward the episiotomy is not appropriate within the first 24 hours following delivery. Heat application during this early stage can increase inflammation and swelling, potentially worsening pain and delaying healing.

Heat therapy is typically recommended after 24 hours to promote circulation and tissue repair, but it's crucial to apply it at the appropriate time.

Choice D rationale:

Preparing a warm sitz bath is a common comfort measure for postpartum perineal care, but it's generally recommended after

Choice A rationale:

Lochia pooling: When a woman lies in bed, gravity causes lochia to pool in the vagina. This can result in a larger amount of

lochia being expelled when she stands up or moves around.

Reassurance: Explaining this physiological process to the client can help to reassure her that the sudden increase in lochia is

normal and not a cause for alarm.

Validation: The nurse should validate the client's feelings of concern, as it is understandable for a new mother to be anxious

about any changes in her body after childbirth.

Education: The nurse should also provide education about lochia, including its typical characteristics, duration, and expected

changes. This can help the client to anticipate and understand her postpartum experience.

Choice B rationale:

Retained placenta: While retained fragments of the placenta can cause increased lochia, this is not the most common

this possibility, especially before further assessment.

Assessment and intervention: If there is a concern for retained placenta, the nurse would conduct a thorough assessment,

including fundal height, uterine tone, and lochia characteristics. Further interventions, such as ultrasound or manual

exploration of the uterus, may be necessary.

Choice C rationale:

Urinary tract infections (UTIs): UTIs can sometimes cause an increase in lochia, but they are not typically associated with a

sudden, large gush of lochia upon standing. Other symptoms of a UTI, such as burning with urination, urgency, or frequency,

would likely be present as well.

Assessment and intervention: If a UTI is suspected, the nurse would assess for urinary symptoms and collect a urine sample

for analysis. Antibiotic treatment would be initiated if a UTI is confirmed.

Choice D rationale:

Lochia progression: The amount of lochia generally decreases over time during the postpartum period. It is heaviest in the first

few days after delivery and gradually tapers off over the course of several weeks.

Inconsistency with presentation: While this statement is true, it does not directly address the client's concern about a sudden