The nurse is performing a postpartum assessment on a newly delivered client. When checking the fundus, there is a gush of blood. The client asks why that is happening. The best response is:

Question

1. "We see this from time to time. It's not a big deal."
2. "The gush is an indication that your fundus isn't contracting."
3. "Don't worry. I'll make sure everything is fine."
4. "Blood has pooled in the vagina while you were in bed."

Answer 1

4
Rationale:
1. Although a gush of blood during fundus assessment is fairly common, this response is not therapeutic because it does not answer the client's question.
2. The fundus might be contracting well. The gush is from pooled lochia in the vagina.
3. This response is not therapeutic, because it focuses on the nurse and has a "don't worry" aspect that most clients find demeaning.
4. Because of the angle of the vagina, lochia pools in the vagina while a woman is lying or semi-sitting in bed, which leads to a gush when fundal massage is undertaken.