Question

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. "Lochia can pool in the vagina while you lie in bed."
Rationale: The client needs to be reassured that this is expected following a period of rest in bed.
B. "You might have retained fragments of your placenta."
Rationale: It is not likely that retained placenta fragments caused this release of lochia.
C. "Urinary tract infections are associated with increased lochia."
Rationale: It is not likely that an infection caused this release of lochi
D. "The amount of lochia increases during the postpartum period."
Rationale: The amount of lochia should decrease during postpartum uterine involution.

Answer 1

The nurse should reassure the client that lochia can pool in the vagina while lying in bed due to rest. Passing a large amount of lochia when first getting out of bed after delivery is expected.

Step-by-step explanation:

The nurse should respond by saying, "Lochia can pool in the vagina while you lie in bed." The client needs to be reassured that this is expected following a period of rest in bed. Lochia is the postpartum vaginal discharge that occurs after delivery, which is made up of uterine lining cells, blood, and other debris. It is normal for a large amount of lochia to be passed when the client first gets out of bed after delivery.

Answer 2

The nurse should inform the client that pooling of lochia is normal when first getting out of bed post-delivery and offer reassurance (option A).

Step-by-step explanation:

The nurse should reassure the client that passing a large amount of lochia is not uncommon when getting out of bed for the first time after delivery. Lochia can indeed pool in the vagina while lying down, leading to a sudden gush when standing up. Uterine lining cells, erythrocytes, leukocytes, and other debris make up lochia, which evolves from lochia rubra to lochia serosa and finally to lochia alba during the postpartum period. The correct response for the nurse to provide would be option A, "Lochia can pool in the vagina while you lie in bed, which might explain the large amount you experienced upon standing," as this option offers a normal explanation and reassurance.

Hence, the answer is option A.