The nurse has completed a postpartum assessment on a patient who delivered 1 hour ago. Which amount of lochia consists of a moderate amount?

Correct Answer: B

Rationale: The correct answer is B (10 to 15 cm (4- to 6-inch) stain on the peripad) because a moderate amount of lochia typically indicates a blood stain of 10 to 15 cm within 1 hour postpartum. This amount of lochia signifies a normal postpartum bleeding pattern. Incorrect answers: A: Saturated peripad indicates a heavy amount of lochia, not moderate. C: 2.5 to 10 cm (1- to 4-inch) stain on the peripad is considered light, not moderate. D: Less than a 1-inch stain on the peripad is minimal lochia, not moderate.

Correct Answer: C

Rationale: The correct answer is C. When assessing the A of REEDA (Redness, Edema, Ecchymosis, Discharge, and Approximation) in wound assessment, nurses should evaluate the edges of the episiotomy. This is important to ensure proper healing and closure of the incision site. Evaluating skin color (A) is important for overall wound assessment but not specifically for the edges of the episiotomy. Edema (B) refers to swelling, which is important to monitor but not specific to the edges of the episiotomy. Checking the episiotomy for discharge (D) is relevant for the "D" component of REEDA but not for the "A" component, which specifically focuses on the edges of the incision.

Correct Answer: D

Rationale: The correct answer is D: Document the finding in the patient’s chart. The fundus being firm and at the umbilicus indicates normal involution after delivery. Documenting this finding is essential for accurate assessment and continuity of care. Informing the health care provider (choice A) is not necessary as the finding is normal. Encouraging the patient to urinate (choice B) is important for postpartum care but not the priority in this situation. Massaging the uterus to expel clots (choice C) is not indicated as the fundus is already firm, indicating proper contraction.

Correct Answer: A

Rationale: The correct answer is A because the absence of swelling or edema to the perineal area indicates that the ice sitz baths have been effective in reducing inflammation and promoting healing. Swelling and edema are common postpartum, and the use of ice sitz baths can help reduce these symptoms. Choice B is incorrect because the patient complaining that the sitz bath is too cold does not provide information on the effectiveness of the treatment, only the patient's comfort level. Choice C is incorrect because the frequency of sitz baths does not necessarily indicate effectiveness. It is more important to assess the outcomes of the treatment rather than the number of baths taken. Choice D is incorrect because the approximation of perineal laceration edges may be influenced by other factors such as suturing technique, rather than the effectiveness of the ice sitz baths.

Correct Answer: A

Rationale: The correct answer is A: Making the birth experience "real." This choice aligns with the concept of emotional processing and integration in the postpartum period. By continually repeating her birth story, the patient is trying to make sense of and come to terms with her experience, making it feel more "real" to her. This process helps her emotionally process the events and transitions she has gone through during labor and birth. Choices B, C, and D are incorrect: B: Accepting her response to labor and birth - This choice focuses more on the patient's emotional response rather than the act of repeating the story. C: Providing others with her knowledge of events - This choice is more about sharing information rather than the internal emotional processing the patient is likely engaging in. D: Taking hold of the events leading to her labor and birth - This choice suggests a sense of control over the events, which may not necessarily be the primary motivation behind the patient's behavior.