The nurse is planning comfort measures to implement for a patient after a vaginal birth. Which measures should the nurse plan to include in the patient’s care plan? (Select all that apply.)

Correct Answer: A

Rationale: The correct answer is A: Sitz baths four times a day. Sitz baths promote healing, reduce swelling, and provide comfort after a vaginal birth. Warm water helps to soothe the perineal area. Choices B, C, and D are incorrect because using warm water alone may not be as effective as sitz baths, topical anesthetic spray may not be necessary for routine care, and ice packs may not be recommended for the first 24 hours due to the risk of vasoconstriction and decreased blood flow to the area.

Correct Answer: A

Rationale: The correct answer is A: rubra. Lochia rubra is bright to dark red, typically occurring on days 1-3 postpartum. This is due to the presence of blood and decidual tissue. Serosa (B) is pinkish-brown and occurs around days 4-10, representing a mix of blood and mucus. Placental (C) is typically expelled within 30 minutes postpartum and consists of dark red blood. Alba (D) is whitish-yellow, appearing around day 10 and lasting up to 6 weeks, indicating the final stage of lochia consisting of leukocytes and decidual tissue.

Correct Answer: D

Rationale: The correct answer is D: diastasis recti abdominus. This term refers to the separation of the rectus abdominis muscles along the midline of the abdomen. This condition commonly occurs after pregnancy due to the stretching of the abdominal muscles. It is important to differentiate diastasis recti from other conditions such as uterine subinvolution, which is the delayed return of the uterus to its normal size postpartum; umbilical hernia, which is a protrusion of abdominal contents through the umbilical ring; and striae, which are stretch marks caused by rapid stretching of the skin. Diastasis recti is characterized by a visible gap between the muscles, often causing a bulge in the midline of the abdomen. Treatment usually involves specific exercises to strengthen the abdominal muscles and improve the condition.

Correct Answer: A

Rationale: The correct answer is A: Contact the health-care provider. Unilateral edema along with a hot, red area on the leg can indicate a potential serious condition such as deep vein thrombosis (DVT). It is crucial to involve the healthcare provider immediately for further evaluation and treatment. Contacting the healthcare provider ensures timely diagnosis and appropriate management. Summary: B: Explaining this as a normal finding is incorrect as it could be a sign of a serious condition. C: Massaging the calf can potentially dislodge a clot in case of DVT, leading to severe complications. D: Offering pain medication without proper evaluation can mask the symptoms and delay necessary medical intervention.

Correct Answer: C

Rationale: The correct answer is C because redness, pain, and heat are warning signs of a possible breast infection or inflammation, such as mastitis. This indicates an abnormality that requires further assessment and intervention. A: Colostrum expressed is a normal occurrence during pregnancy or after delivery and is not a warning sign. B: Nipple everted is also a normal anatomical variation and not a warning sign. D: Filling with milk is expected during lactation and not necessarily indicative of a problem.