A nurse is assigned to care for four clients who are each one day postpartum. Following the nurse performing an initial assessment on each client, which finding would prompt further evaluation by the nurse?
A nurse is assigned to care for four clients who are each one day postpartum. Following the nurse performing an initial assessment on each client, which finding would prompt further evaluation by the nurse?
A. A client complaining of mild pain
[2%]
B. A client with a pulse rate of 65 bpm
[6%]
C. A client with colostrum discharge from both breasts
[1%]
D. A client with red, foul-smelling lochia
[91%]
Statistics
Subject/Lesson
Subject
Maternal & Newborn Health
Lesson
Postpartum
Client Need
Test Plan
Health Promotion and Maintenance
Related Topic
Ante/Intra/Postpartum and Newborn Care
Item Type
Item Type
Application
Explanation
Choice D is correct. Lochia is vaginal discharge following childbirth. At one day postpartum, the client's discharge is expected to be dark red or red-brown, similar to a heavy menstrual discharge, and should have a fleshy, earthy odor. A client with foul-smelling lochia should prompt further evaluation by the nurse, as lochia which smells foul or fishy could indicate infection. Additionally, the nurse may need to elaborate further on the discharge color rather than simply using the term "red," as the anticipated discharge color at this point in the postoperative period should likely be darker in color.
Choice A is incorrect. It is reasonable for a client who is one day postpartum to have mild pain; therefore, further assessment is not required.
Choice B is incorrect. A pulse rate of 65 beats per minute is within normal limits and is not cause for concern.
Choice C is incorrect. Colostrum discharge from the client's bilateral breasts is anticipated in a client who is one day postpartum and, therefore, does not warrant further assessment.
Learning Objective
Recognize that a finding of foul-smelling lochia in a postpartum client warrants additional evaluation by a nurse.
Related Videos
2 Key Topics
Chorioamnionitis
30.4 Intrapartum Complications
Additional Info
- Lochia consists of the contents from the uterus accumulated during the nine months of pregnancy.
- The lochia will have an odor similar to a typical menstrual period.
- Because estimating the amount of lochia on a peripad (perineal pad) is difficult, nurses frequently document lochia in terms that are difficult to quantify, such as scant, moderate, or heavy.
- Typically, lochia flow is greater immediately after delivery and gradually decreases.
- Lochia flow is less following a cesarean birth, as some of the endometrial lining is removed during surgery.
- The lochia of a client who had a cesarean birth will go through the same phases as that of a client who had a vaginal birth, with the only exception of the amount being reduced.
