Nursing Interventions for Lochia
Total Questions : 12
Showing 12 questions, Sign in for more(select all that apply) A nurse is teaching a breastfeeding client about engorgement prevention and management.
What should the nurse include in the teaching?
No explanation
A nurse is educating a postpartum client about resuming sexual intercourse after delivery.
What information should the nurse provide to the client?
Explanation
The correct answer is choice B. Sexual intercourse may be uncomfortable due to vaginal dryness.According to Mayo Clinic, hormonal changes after pregnancy might leave the vagina dry and tender, especially if the client is breast-feeding.
This can cause pain and discomfort during sex.
The client can use lubricant or try alternative forms of intimacy to ease the discomfort.
Choice A is wrong because sexual intercourse can be resumed after 4 weeks postpartum only if the client feels comfortable and has no complications.The general recommendation is to wait until 6 weeks postpartum or until the provider clears the client for sex.
Choice C is wrong because sexual intercourse should not be avoided until lochia alba stops.
Lochia alba is the last stage of postpartum bleeding that lasts from 10 to 14 days after delivery.The client can resume sex before lochia alba stops if they feel ready and use contraception to prevent pregnancy.
Choice D is wrong because sexual intercourse may not cause uterine bleeding or infection if the client follows proper hygiene and uses protection.The risk of complications is highest during the first two weeks after delivery, but it decreases after that.
A nurse is assessing a client who is 2 days postpartum.
Which of the following findings should the nurse expect?
Explanation
The correct answer is choice A. Lochia rubra.This is because lochia rubra is the first stage of postpartum bleeding and discharge, which lasts for about three to four days after giving birth.Lochia rubra is dark or bright red in color and contains blood, mucus, uterine tissue and other materials from the uterus.
Choice B.Lochia serosa is wrong because lochia serosa is the second stage of postpartum bleeding and discharge, which lasts for four to 12 days after giving birth.Lochia serosa is pinkish brown in color and thinner and more watery than lochia rubra.
Choice C.Lochia alba is wrong because lochia alba is the third and final stage of postpartum bleeding and discharge, which lasts from about 12 days to six weeks after giving birth.Lochia alba is yellowish white in color and contains little to no blood.
Choice D.No lochia is wrong because lochia is a normal part of the postpartum healing process and does not usually cause complications.Lochia helps clear the uterus of any residual tissue, blood and fluid after pregnancy.No lochia may indicate a problem such as infection or retained placenta.
A nurse is caring for a client who is 4 days postpartum and has a vaginal birth with an episiotomy.
The client reports that her perineal area is sore and asks the nurse what she can do to relieve the discomfort.
Which of the following responses should the nurse make?
Explanation
The correct answer is choice C.“Take a warm sitz bath.” A sitz bath is a shallow bath that covers the hips and buttocks and can help reduce swelling and discomfort in the perineal area after delivery.A warm sitz bath can also ease the pain of urination and promote blood flow to the area for faster healing.
Choice A is wrong because applying heat to the perineum can increase inflammation and pain.Choice B is wrong because using an ice pack on the perineum can cause an uncomfortable, sudden sensation of coldness on the skin.Choice D is wrong because using a heating pad on the abdomen has no effect on the perineal area and can also increase inflammation.
A nurse is caring for a client who is 5 days postpartum and has a vaginal birth with an episiotomy.
The client reports that she has pain in her perineal area and asks the nurse what she can do to relieve the discomfort.
Explanation
The correct answer is choice D.“You should avoid straining during bowel movements.” This is because straining can cause pain and bleeding in the perineal area, especially if the client has an episiotomy or hemorrhoids.Straining can also worsen the damage to the pelvic floor muscles or the anal sphincter muscles that might have occurred during delivery.
Choice A is wrong because taking a laxative can cause diarrhea, dehydration, and electrolyte imbalance.Laxatives should only be used if prescribed by a health care provider.
Choice B is wrong because increasing fluid intake alone is not enough to prevent or treat constipation.Fluid intake should be combined with adequate fiber intake and physical activity.
Choice C is wrong because increasing fiber intake alone is not enough to prevent or treat constipation.Fiber intake should be combined with adequate fluid intake and physical activity.
Normal ranges for fluid intake are about 2 to 3 liters per day for a lactating woman and about 1.5 to 2 liters per day for a non-lactating woman.Normal ranges for fiber intake are about 25 to 35 grams per day for adults.Normal ranges for physical activity are about 150 minutes of moderate-intensity exercise per week for healthy adults.
A nurse is caring for a client who is 5 days postpartum and has a vaginal birth with an episiotomy.
The client reports that she has pain in her perineal area and asks the nurse what she can do to relieve the discomfort.
Which of the following responses should the nurse make?
Explanation
The correct answer is choice C.“Take a warm sitz bath.” A sitz bath is a shallow bath that covers the perineal area and can help relieve pain and swelling after a vaginal birth with an episiotomy.A sitz bath can also promote healing and prevent infection by keeping the area clean.
Choice A is wrong because applying heat to the perineum can increase swelling and inflammation.Choice B is wrong because ice packs should only be applied for 10 to 20 minutes at a time and removed for at least 10 minutes before reapplying.Ice packs are most effective in the first 24 to 72 hours after birth.
Choice D is wrong because using a heating pad on the abdomen has no effect on the perineal pain.Heating pads can also cause burns if used for too long or at a high temperature.
A nurse is caring for a client who is 1 week postpartum and has a vaginal birth with an episiotomy.
The client reports that she has pain in her perineal area and asks the nurse what she can do to relieve the discomfort.
Which of the following responses should the nurse make?
Explanation
The correct answer is choice C.“Take a warm sitz bath.” A sitz bath is a shallow bath that covers the perineum and can help relieve pain and swelling after a vaginal birth with an episiotomy.A sitz bath can also promote healing and prevent infection by keeping the area clean.
Choice A is wrong because applying heat to the perineum can increase inflammation and delay healing.Choice B is wrong because using an ice pack on the perineum is only recommended for the first 24 hours after delivery to reduce swelling.After that, ice can cause tissue damage and slow down blood flow to the area.Choice D is wrong because using a heating pad on the abdomen has no effect on the perineal pain and can also cause burns or overheating.
Normal ranges for postpartum perineal pain vary depending on the type and degree of injury, but generally it should improve within a few weeks.If the pain persists or worsens, or if there are signs of infection such as fever, foul-smelling discharge, or redness, it is important to seek medical attention.
A nurse is assessing the amount, color, odor, consistency, and presence of clots or tissue in the lochia of a postpartum client.
Which of the following findings should the nurse report as abnormal?
Explanation
The correct answer is choice D. Large clots on day 3 postpartum.This is because large clots indicate excessive bleeding and may be a sign of postpartum hemorrhage, which is a rare but potentially fatal condition that requires immediate medical attention.
Choice A is wrong because lochia rubra, which is dark or bright red blood, is normal for the first three to four days after birth.
Choice B is wrong because lochia serosa, which is pinkish brown discharge that’s less bloody looking, is normal for four to 12 days after birth.
Choice C is wrong because lochia alba, which is yellowish white discharge with little to no blood, is normal from about 12 days to six weeks after birth.
Normal ranges for lochia are:
• Lochia rubra: lasts for three to four days, flows like a heavy period, small clots are normal.
• Lochia serosa: lasts for four to 12 days, flow is moderate, less clotting or no clots.
• Lochia alba: lasts from about 12 days to six weeks, light flow or spotting, no clots.
A nurse is caring for a postpartum client who has a boggy uterus.
Which of the following actions should the nurse take?
Explanation
The correct answer is choice B. Encourage the woman to empty her bladder regularly.A boggy uterus is a condition that occurs when the uterus fails to contract properly after childbirth, leading to excessive bleeding and possible postpartum hemorrhage.One of the causes of a boggy uterus is bladder distension, which can prevent the uterus from contracting and returning to its normal position.Therefore, encouraging the woman to empty her bladder regularly can help reduce the risk of a boggy uterus and postpartum hemorrhage.
Choice A is wrong because administering oxytocics as prescribed is not an action that the nurse should take, but rather the physician or midwife.Oxytocics are medications that stimulate uterine contractions and are used to treat a boggy uterus when other methods fail.
Choice C is wrong because providing a peri-bottle with warm water for cleansing after each voiding or bowel movement is not an action that can prevent or treat a boggy uterus.It is a hygiene measure that can help prevent infection and promote healing of the perineal area after childbirth.
Choice D is wrong because advising the woman to avoid tampons is not an action that can prevent or treat a boggy uterus.It is a precautionary measure that can help prevent infection and irritation of the vaginal canal after childbirth.Tampons should be avoided for at least six weeks after delivery.
A nurse is assessing a postpartum client’s lochia and notes that it has an unpleasant odor.
Which of the following actions should the nurse take?
Explanation
The correct answer is choice C. Palpate the fundus for firmness.This is because an unpleasant odor of lochia (postpartum vaginal discharge) can indicate an infection or retained placental fragments in the uterus.Palpating the fundus can help assess the uterine involution and detect any abnormalities.
Choice A is wrong because documenting the finding is not enough to address the potential problem.The nurse should also notify the provider and take further actions as ordered.
Choice B is wrong because encouraging the woman to empty her bladder regularly is not related to the odor of lochia.It is a general measure to prevent urinary tract infections and promote uterine contraction.
Choice D is wrong because administering oxytocics as prescribed is not a nursing action for lochia with an unpleasant odor.Oxytocics are drugs that stimulate uterine contractions and are used to prevent or treat postpartum hemorrhage.
They do not affect the infection or retention of placental fragments.
Normal ranges for lochia are:
• Lochia rubra: dark or bright red blood, lasts for 3 to 4 days, flows like a heavy period, small clots are normal.
• Lochia serosa: pinkish brown discharge, lasts for 4 to 12 days, thinner and more watery than lochia rubra, moderate flow, less or no clots.
• Lochia alba: yellowish white discharge, lasts from 12 days to 6 weeks, light flow or spotting, no clots.
Lochia should have a stale, musty or metallic odor like menstrual blood.It should not smell fishy or foul, which can indicate an infection.
A nurse is caring for a postpartum client who reports heavy bleeding and large clots in her lochia.
Which of the following actions should the nurse take?
Explanation
The correct answer is choice C. Palpate the fundus for firmness.This is because uterine atony is the most common cause of postpartum hemorrhage and palpating the fundus can help assess the tone of the uterus and stimulate contractions.If the fundus is boggy or soft, the nurse should massage it gently until it becomes firm.
Choice A is wrong because documenting the finding in the client’s chart is not an immediate action to stop the bleeding and may delay the treatment.
Choice B is wrong because encouraging the woman to empty her bladder regularly is a preventive measure for postpartum hemorrhage, not a treatment.A full bladder can displace the uterus and prevent it from contracting properly.
Choice D is wrong because notifying the provider is not enough to manage postpartum hemorrhage.The nurse should initiate interventions such as oxytocin administration, uterine massage, bimanual compression, fluid replacement, and blood transfusion as needed.
Notifying the provider should be done after or along with these interventions.
A nurse is teaching a postpartum client about lochia and when to report abnormal findings.
Which of the following statements by the client indicates an understanding of the teaching?
Explanation
The correct answer is choice C.“I should report foul odor.” This indicates an understanding of the teaching because foul odor is a sign of infection and should be reported to the healthcare provider.Lochia is the normal vaginal discharge after childbirth that contains blood, mucus, uterine tissue and other materials.It has three stages: lochia rubra (red), lochia serosa (pinkish brown) and lochia alba (yellowish white).Lochia usually lasts for four to eight weeks.
Choice A is wrong because heavy bleeding is expected for the first few days after delivery and then gradually decreases.However, if the bleeding is excessive or does not slow down, it could indicate a postpartum hemorrhage and should be reported immediately.
Choice B is wrong because abdominal pain is normal after delivery as the uterus contracts and shrinks back to its pre-pregnancy size.However, if the pain is severe or does not improve with pain medication, it could indicate a complication such as infection or retained placenta and should be reported.
Choice D is wrong because perineal itching is common after delivery due to healing of the tissues and stitches.However, if the itching is accompanied by redness, swelling, discharge or fever, it could indicate an infection and should be reported.
Sign Up or Login to view all the 12 Questions on this Exam
Join over 100,000+ nursing students using Nursingprepexams’s science-backend flashcards, practice tests and expert solutions to improve their grades and reach their goals.
Sign Up Now
