A postpartum client becomes concerned when a gush of blood occurs during the fundal assessment. What should the nurse explain about this occurrence?
1. "Do not worry. I will make sure everything is fine."
2. "We see this from time to time. It's not a big deal."
3. "Blood has pooled in the vagina while you were in bed."
4. "The gush is an indication that your fundus is not contracting."
3
Explanation:
1. This response is not therapeutic because it focuses on the nurse and has a "do not worry" aspect that is demeaning.
2. Although a gush of blood during fundus assessment is fairly common, this response is not therapeutic because it does not address the client's concern.
3. Because of the angle of the vagina, lochia pools in the vagina while a woman is lying or semisitting in bed, which leads to a gush when fundal massage is performed.
4. The fundus might be contracting well. The gush is from pooled lochia in the vagina.
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