Nokea
Two days after delivery, a postpartum client prepares for discharge. What should the nurse teach her about lochia flow?
- A. Lochia does change color but goes from lochia rubra (bright red) on days 1-3, to lochia serosa (pinkish brown) on days 4-9, to lochia alba (creamy white) days 10-21.
- B. Numerous clots are abnormal and should be reported to the physician.
- C. Saturation of the perineal pad is considered abnormal and may indicate postpartum hemorrhage.
- D. Lochia normally lasts for about 21 days, and changes from a bright red, to pinkishbrown, to creamy white.
Correct Answer: D
Rationale: The correct answer is D. Lochia normally lasts for about 21 days, and changes from bright red to pinkish-brown to creamy white. This is accurate because the process of lochia flow typically follows this pattern as the uterus sheds its lining post-delivery. Lochia rubra occurs in the first few days due to blood, then transitions to serosa and alba as the bleeding decreases. Choice A is incorrect as it presents the correct information but in a confusing manner. Choices B and C are incorrect because they focus on abnormal findings rather than the normal progression of lochia.
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A nurse is caring for a child with measles.
- A. "Provide diversional activities such as video games."'
- B. "Maintain isolation for 48 hr after the rash resolves."'
- C. "Keep the child warm with adequate undergarments and bedding."'
- D. "Administer vitamin A supplements as prescribed."'
Correct Answer: D
Rationale: The correct answer is D because administering vitamin A supplements is a standard treatment for measles to reduce complications and improve recovery. Vitamin A deficiency is common in children with measles, and supplementation can help boost the immune system and reduce the severity of the illness. Providing diversional activities (choice A) may be suitable but does not directly address the medical needs of the child. Maintaining isolation (choice B) is important but typically lasts until 4 days after rash onset, not just 48 hours after rash resolution. Keeping the child warm (choice C) is a general comfort measure and may not directly impact measles treatment.
During the first twelve hours following a normal vaginal delivery, the client voids 2,000 mL of urine. How should the nurse interpret this finding?
- A. Urinary tract infection
- B. High output renal failure
- C. Excessive use of IV fluids during delivery
- D. Normal diuresis after delivery
Correct Answer: D
Rationale: The correct interpretation is D: Normal diuresis after delivery. After childbirth, diuresis is common due to the body eliminating excess fluid retained during pregnancy. This process helps reduce swelling and aids in returning to pre-pregnancy state. Voiding 2,000 mL in the first twelve hours is within the expected range for postpartum diuresis. Choices A, B, and C are incorrect as they do not align with the typical physiologic response to childbirth. Urinary tract infection and high output renal failure would present with other symptoms, while excessive IV fluid use would not explain the timing or volume of urine output.
A nurse is caring for a 4-year-old client with full-thickness burns. Which of the following nursing actions are essential for the care of this child? (Select all that apply.)
- A. Monitor level of consciousness
- B. Maintain intravenous fluids
- C. Document vital signs
- D. Provide a low-calorie,high carbohydrate diet
Correct Answer: A,B,C
Rationale: Level of consciousness, IV fluids, vital signs, and urinary output are critical in burn management; a high-protein, high-calorie diet is recommended instead of a low-calorie diet.
A woman in active labor receives a narcotic analgesic for pain control. If the narcotic is given a half an hour before delivery, which effect will the medication have on the infant?
- A. It will cause the infant's blood sugar to fall.
- B. It will cause the infant's respiratory rate to decrease.
- C. It will cause the infant's heart rate to increase.
- D. It will cause the infant's movements to be hyperactive.
Correct Answer: B
Rationale: The correct answer is B: It will cause the infant's respiratory rate to decrease. Narcotic analgesics can cross the placenta and affect the baby. These medications can depress the respiratory drive of the newborn, leading to decreased respiratory rate. This effect is particularly pronounced if the narcotic is given shortly before delivery when the drug levels in the infant's system are highest. The other choices are incorrect because: A) Narcotics are not known to directly affect blood sugar levels in infants. C) Narcotics typically cause a decrease, rather than an increase, in heart rate. D) Narcotics are more likely to cause sedation and decreased movements rather than hyperactivity in newborns.
A woman enters the birthing center in active labor. She tells the nurse that her membranes ruptured 26 hours ago. The nurse immediately takes the client's vital signs. Which is the rationale for the nurse's actions?
- A. Pulse rates rise the longer the membranes are ruptured
- B. Respiratory rates decrease due to lack of fluid in the uterus
- C. Prolonged rupture of membranes can lead to transient hypertension
- D. Infection is a complication of prolonged rupture of membranes
Correct Answer: D
Rationale: The correct answer is D. When the membranes rupture, it increases the risk of infection as it provides a direct pathway for bacteria to enter the uterus. Taking vital signs is crucial to monitor for signs of infection such as fever, tachycardia, and hypotension. Elevated temperature and increased heart rate can indicate an infection. Choice A is incorrect because pulse rate may not necessarily rise with prolonged rupture of membranes. Choice B is also incorrect as respiratory rates are not directly affected by ruptured membranes. Choice C is incorrect as prolonged rupture can lead to infection rather than transient hypertension.