A newly delivered mother states, 'I have not had any alcohol since I decided to become pregnant. I have decided not to breastfeed because I would really like to go out and have a good time for a change.' Which of the following is the best response by the nurse?

Correct Answer: D

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

Correct Answer: D

Rationale: The correct answer is D because the normal progression of lochia after childbirth is from rubra (red) to serosa (pinkish-brown) to alba (yellow-white). This signifies the normal healing process of the uterus. Choices A, B, and C are all normal postpartum events. Diuresis and diaphoresis help eliminate excess fluid from pregnancy, flatulence and constipation can occur due to hormonal changes and decreased muscle tone, and extreme hunger and thirst are common as the body recovers from childbirth.

Correct Answer: C

Rationale: Rationale: Postpartal overdistention of the bladder and urinary retention can lead to urinary tract infection and uterine rupture. When the bladder is overdistended, it can cause urinary stasis, leading to bacterial growth and increasing the risk of urinary tract infections. Additionally, the pressure from the distended bladder can impede uterine contractions, potentially causing uterine rupture. Fever and increased blood pressure (Choice A) are not direct complications of bladder overdistention. Postpartum hemorrhage and eclampsia (Choice B) are not typically associated with bladder overdistention. Postpartum hemorrhage and urinary tract infection (Choice D) are not as directly related to the complications of bladder overdistention as urinary tract infection and uterine rupture are.

Correct Answer: A

Rationale: The correct answer is A, a distended bladder. When the fundus is palpated on the right side above the expected level, it indicates that the bladder is full and pushing the uterus upward and to the right. This can interfere with the normal descent of the uterus during involution, leading to the fundus being higher than expected. Choice B, normal involution, is incorrect as it does not explain the fundus being palpated above the expected level. Choice C, lying on her right side too long, is incorrect as body position does not typically result in the fundus being displaced. Choice D, stretched ligaments that are unable to support the uterus, is incorrect as stretched ligaments would not cause the fundus to be palpated above the expected level; rather, it would lead to a lower position of the uterus.

Correct Answer: C

Rationale: The correct answer is C: Early and frequent ambulation. This measure is optimal to prevent abdominal distention following a cesarean birth because it helps promote bowel motility and gas expulsion. Ambulation stimulates peristalsis, preventing gas accumulation and reducing the risk of distention. Rectal suppositories (A) may help with constipation but do not address the root cause of distention. Carbonated beverages (B) can exacerbate bloating and gas production. Tightening and relaxing abdominal muscles (D) may provide some relief but are not as effective as promoting ambulation for preventing abdominal distention.