The nurse is planning care for a client during the fourth stage of labor. Which interventions should the nurse plan to implement? (Select all that apply.)
A) Offer the client a warm blanket.
B) Place an ice pack on the perineum.
C) Massage the uterus if it is boggy.
D) Delay breastfeeding until the client is rested.
E) Explain to the client that the lochia will be light pink in color.

Question

Quizplus · Accepted Answer

The fourth stage of labor lasts from the birth of the placenta through the first 1 to 4 hours after birth. Many women are chilled after birth. A warm blanket, hot drink, or soup may help relieve the chill and make the woman more comfortable. Localized discomfort from birth trauma such as lacerations, episiotomy, edema, or hematoma is evident as the effects of local and regional anesthetics diminish. Ice packs on the perineum limit this edema and hematoma formation. A soft (boggy) uterus and increasing uterine size are associated with postpartum hemorrhage because large blood vessels at the placenta site are not compressed. The uterus should be massaged if it is not firm. The fourth stage is the best time to initiate breastfeeding if maternal and infant problems are absent. The vaginal drainage after childbirth is called lochia. The three stages are lochia rubra, lochia serosa, and lochia alba. Lochia rubra, consisting mostly of blood, is present in the fourth stage of labor. The color of the lochia will be bright red not pink.

The Nurse Is Planning Care for a Client During the Fourth