A nurse is assessing a postpartum client 24 hours after vagi… | 마이메르시 MyMerci
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Maternal Newborn Health
문제

A nurse is assessing a postpartum client 24 hours after vaginal delivery. Which assessment finding would be considered normal for this time period?

해설
Normal postpartum findings at 24 hours include lochia rubra with small clots and mild odor. Other findings are abnormal: fundus above umbilicus suggests uterine atony, fever may indicate infection, and severe cramping pain requires further assessment.
같은 주제 다음 문제A nurse is assessing a postpartum client 24 hours after vaginal delivery. Which assessment…이 문제가 수록된 문제집[개념+기출] 엔클렉스(NCLEX),이거 하나면 됩니다89,000원 · 무료 체험 가능

심화 해설

Normal Postpartum Assessment at 24 Hours

The correct answer is Lochia rubra with small clots and mild odor.

At 24 hours postpartum, the uterine lining is shedding the debris from the placental site, resulting in lochia rubra. This discharge consists of blood, decidual tissue, and trophoblastic remnants. The presence of small clots is expected, particularly after periods of recumbency when blood pools in the vagina, and a mild, fleshy odor is characteristic of normal lochia. A survey on women's experiences of vaginal loss after childbirth confirms that the characteristics of normal lochia—including its color, amount, and presence of clots—are highly variable, and findings such as small clots and a non-foul odor fall well within the expected range during the first 24 hours [1]. A foul-smelling odor would suggest infection, but a mild odor is not a concern.

The other options represent findings that deviate from the expected postpartum course and require further investigation:
- A fundus palpated 3 cm above the umbilicus indicates uterine atony or a full bladder displacing the uterus, rather than the expected firm, midline fundus at or below the level of the umbilicus.
- A temperature of 101.2°F (38.4°C) exceeds the common transient postpartum temperature elevation and may signal endometritis or other infection, especially when sustained beyond the first 24 hours.
- Severe cramping pain rated 8/10 is disproportionate to normal afterpains, which are typically mild to moderate and respond to comfort measures; severe pain could indicate retained placental fragments or developing infection.
References (research sources)
  • [1]
    A survey of women's experiences of vaginal loss from 24 hours to three months after childbirth (the BLiPP study).Research articleMarchant S, Alexander J, Garcia J, Ashurst H, Alderdice F, Keene J. (1999) · DOI: 10.1016/s0266-6138(99)90002-5

임상 시나리오

Clinical Scenario

A nurse is performing a routine assessment on a client 24 hours after an uncomplicated vaginal delivery. The client reports feeling tired but is otherwise comfortable. Vital signs are stable except as noted. The nurse observes the perineal pad and palpates the fundus.

Assessment Findings
  • Lochia: Rubra, moderate amount, a few small clots noted, mild fleshy odor
  • Fundus: Firm, midline, 1 cm below the umbilicus
  • Temperature: 99.1°F (37.3°C)
  • Pain: Reports mild intermittent cramping, 2/10
Nursing Actions
  1. Document the lochia characteristics, fundal height, and tone as normal postpartum findings.
  2. Educate the client on expected lochia progression: rubra (days 1-3), serosa (days 4-10), alba (weeks 2-6).
  3. Instruct the client to report any foul odor, large clots (larger than a golf ball), or saturation of a perineal pad within 1 hour.
  4. Encourage ambulation and voiding every 2-3 hours to prevent bladder distention and uterine displacement.
  5. Reassess fundus and lochia every shift and after breastfeeding, as oxytocin release can increase afterpains and flow.
Clinical Reasoning

Lochia rubra with small clots and a mild odor is expected at 24 hours postpartum due to normal uterine involution and shedding of the placental site. A firm, midline fundus at or below the umbilicus confirms adequate contraction. Deviations such as a high fundus, foul odor, large clots, or severe pain would warrant immediate investigation for uterine atony, retained placental fragments, or infection.

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