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.'

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A reason:

Panting can help prevent premature pushing and reduce the risk of cervical edema or laceration. The client should be instructed to take short, shallow breaths through her mouth during contractions until she reaches 10 cm of dilation.

Choice B reason:

Assessing the perineum for signs of crowning is not a priority at this stage, as the fetus is not yet at a low enough station to be visible. Crowning usually occurs when the fetus is at +4 or +5 station.

Choice C reason:

Assisting the client into a comfortable position is important, but it does not address the urge to push. The client should be encouraged to change positions frequently to promote fetal descent and comfort.

Choice D reason:

Helping the client to the bathroom to empty her bladder is not advisable, as it can increase the risk of cord prolapse or rupture of membranes. The client should have an indwelling catheter inserted if she is unable to void spontaneously.

A. Prepare the client for an emergency cesarean birth. B. Cover the cord with a sterile, moist saline dressing. C. Explain to the client what is happening. D. Place the client in a knee-chest or Trendelenburg position

Correct Answer is D

Explanation

Choice D reason:
Placing the client in a knee-chest or Trendelenburg position is the first action the nurse should take, as it can relieve pressure on the cord and prevent compression and fetal hypoxia. The nurse should also use a sterile gloved hand to hold the presenting part oﬀ the cord.

Choice A reason:
Preparing the client for an emergency cesarean birth is an important action, as it can facilitate prompt delivery and prevent fetal compromise. However, this is not the first action the nurse should take, as it does not address the immediate problem of cord prolapse.

Choice B reason:
Covering the cord with a sterile, moist saline dressing is an important action, as it can prevent drying and infection of the cord. However, this is not the first action the nurse should take, as it does not address the immediate problem of cord compression.

Choice C reason:
Explaining to the client what is happening is an important action, as it can provide emotional support and education for the client. However, this is not the first action the nurse should take, as it does not address the immediate problem of cord prolapse.

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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?

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Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

A nurse is assisting with the care of a client who is in the first stage of labor. The nurse observes the umbilical cord protruding from the vagina. Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

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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?

A nurse is collecting data from a client who is postpartum. Which of the following findings should alert the nurse to the possibility of a postpartum complication?

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?