A nurse is performing an assessment on a postpartum patient.
The uterus is found to be displaced to the right.
Which of the following actions should the nurse take?

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

Choice A rationale:

Retraction of the fetal head against the maternal perineum is a classic sign that the shoulders are about to be delivered. This is

known as the "turtle sign" because the fetal head appears to retract back into the body like a turtle's head.

It is important for the nurse to be prepared to assist with the delivery of the shoulders to ensure a safe and smooth delivery.

This includes:

Positioning the mother appropriately, such as in the McRoberts maneuver or a hands-and-knees position.

Applying gentle downward traction on the fetal head to help deliver the anterior shoulder.

Rotating the fetal shoulders as needed to facilitate delivery.

Monitoring the fetal heart rate closely for any signs of distress.

Choice B rationale:

While encouraging the mother to rest between contractions is important for conserving energy, it is not the priority action

when the fetal head is retracting. The nurse's focus should be on preparing for the delivery of the shoulders.

Choice C rationale:

Checking the mother's blood pressure is a routine part of labor and delivery care, but it is not specifically indicated when the

fetal head is retracting. There is no evidence to suggest that retraction of the fetal head is associated with changes in maternal

blood pressure.

Choice D rationale:

Administering oxygen to the mother may be helpful in some cases, such as if the fetal heart rate is showing signs of distress.

However, it is not the priority action when the fetal head is retracting. The focus should be on preparing for the delivery of the

shoulders.