A nurse is assisting a client out of bed for the first time since delivery. The client becomes frightened when she passes a large amount of lochia.
Which of the following responses should the nurse make?
'Lochia can pool in the vagina while you lie in bed.'
'You might have retained fragments of your placenta.'
'The amount of lochia increases during the postpartum period.'
'Urinary tract infections are associated with increased lochia.'
The Correct Answer is A
Choice A reason: This is the most appropriate response because it reassures the client that the amount of lochia she passed is normal and expected after lying down for a long time. Lochia is the vaginal discharge that occurs after childbirth, consisting of blood, mucus, and uterine tissue. It usually decreases in amount and changes in color over time, from red to pink to brown to yellow.
Choice B reason: This is an incorrect response because it implies that the client has a complication that requires further evaluation. Retained placental fragments can cause excessive bleeding, infection, and uterine atony. The nurse should not alarm the client with this possibility without evidence.
Choice C reason: This is an incorrect response because it contradicts the normal patern of lochia. The amount of lochia usually decreases during the postpartum period, not increases. If the client has an increase in lochia, it could indicate a problem such as infection, subinvolution, or hemorrhage.
Choice D reason: This is an incorrect response because it confuses the client with unrelated information. Urinary tract infections are not associated with increased lochia. They are caused by bacteria entering the urinary tract and can cause symptoms such as dysuria, frequency, urgency, and hematuria. The nurse should not suggest that the client has a urinary tract infection without evidence.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Position the client on her left side is incorrect, as this action is not indicated for a client who has a boggy and displaced fundus. Positioning the client on her left side can enhance uterine blood flow and placental perfusion, but it does not address the cause of uterine atony or bladder distension.
Choice B reason: Encourage the client to perform Kegel exercises is incorrect, as this action is not indicated for a client who has a boggy and displaced fundus. Kegel exercises can strengthen the pelvic floor muscles and prevent urinary incontinence, but they do not affect the uterine tone or position.
Choice C reason: Ask the client to rate her pain is incorrect, as this action is not a priority for a client who has a boggy and displaced fundus. Asking the client to rate her pain can provide information about the need for analgesics, but it does not address the risk of hemorrhage or infection due to uterine atony or bladder distension.
Choice D reason: Assist the client to the bathroom to void is correct, as this action can resolve the problem of a boggy and displaced fundus. A boggy and displaced fundus indicates uterine atony and bladder distension, which can interfere with uterine contraction and involution and increase the risk of hemorrhage and infection. The nurse should assist the client to empty their bladder and then massage the fundus until it becomes firm and midline.
Correct Answer is B
Explanation
Choice A reason: The cervix is effaced 3 cm, it is dilated 30%, and the presenting part is 1 cm above the ischial spines is incorrect, as this does not follow the correct order and measurement of cervical assessment. Cervical effacement is measured in percentage, not in centimeters, and it indicates the thinning or shortening of the cervix. Cervical dilation is measured in centimeters, not in percentage, and it indicates the opening or widening of the cervix.
Choice B reason: The cervix is dilated 3 cm, it is effaced 30%, and the presenting part is 1 cm above the ischial spines is correct, as this follows the correct order and measurement of cervical assessment. Cervical dilation, effacement, and station are recorded in that order to describe the progress of labor. Station refers to the relationship between the presenting part of the fetus and the maternal pelvis, measured by the level of the ischial spines. A negative station means that the presenting part is above the spines, while a positive station means that it is below.
Choice C reason: The cervix is effaced 3 cm, it is dilated 30%, and the presenting part is 1 cm below the ischial spines is incorrect, as this does not follow the correct order and measurement of cervical assessment. Cervical effacement is measured in percentage, not in centimeters, and it indicates the thinning or shortening of the cervix. Cervical dilation is measured in centimeters, not in percentage, and it indicates the opening or widening of the cervix.
Choice D reason: The cervix is dilated 3 cm, it is effaced 30%, and the presenting part is 1 cm below the ischial spines is incorrect, as this does not match the documentation of station. A negative station means that the presenting part is above the spines, while a positive station means that it is below.
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