Nokea
A woman will be discharged 48 hours after a vaginal delivery. When planning discharge teaching, the nurse would include what information about lochia?
- A. Lochia should disappear 2 to 4 weeks postpartum.
- B. It is normal for the lochia to have a slightly foul odor.
- C. A change in lochia from pink to bright red should be reported.
- D. A decrease in flow will be noticed with ambulation and activity.
Correct Answer: C
Rationale: A return to bright red lochia rubra may indicate a late postpartum hemorrhage and must be reported.
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On the second postpartum day, a mother bathed her newborn for the first time. She tells the nurse, 'I don't think I did it right.' What postpartum psychological stage is this woman most likely in based on this comment?
- A. Taking in
- B. Taking hold
- C. Letting go
- D. Settling down
Correct Answer: B
Rationale: In phase 2, taking hold, the mother begins to initiate action and becomes interested in caring for the infant. In doing so, she may become critical of her performance.
What would the nurse expect to find when assessing the fundus of the uterus immediately after delivery?
- A. Well-contracted with its upper border at or just below the umbilicus
- B. Well-contracted with its upper border three or four fingerbreadths above the umbilicus
- C. Relaxed with its upper border level with the umbilicus
- D. Relaxed with its upper border two or three fingerbreadths below the umbilicus
Correct Answer: A
Rationale: Immediately after the placenta is expelled, the uterine fundus can be felt as a firm mass, about the size of a grapefruit, at the level of the umbilicus.
Which assessments would lead the nurse to determine the gestational age of the infant as preterm? (Select all that apply.)
- A. Thin, transparent skin
- B. Vernix only in the body creases
- C. Folded ear springs back slowly
- D. Breast tissue under the nipple
- E. Creases over entire sole
Correct Answer: A,C
Rationale: The only signs of preterm are the thin skin and the slowly responding ear.
In the recovery room, the nurse checks the newly delivered woman's fundus following a cesarean section. How would the nurse proceed with this assessment?
- A. Palpate from the midline to the side of the body.
- B. Palpate from the symphysis to the umbilicus.
- C. Palpate from the side of the uterus to the midline.
- D. Massage the abdomen in a circular motion.
Correct Answer: C
Rationale: The fundus is checked gently by walking the fingers from the side of the uterus to the midline.
A postpartum woman is not immune to rubella. What will the nurse expect?
- A. The rubella virus vaccine should be administered before discharge.
- B. The woman should receive the rubella virus vaccine at her 6-week postpartum checkup.
- C. The woman should be instructed not to get pregnant until she receives the rubella vaccine.
- D. No intervention is indicated at this time because the woman is not at risk for rubella.
Correct Answer: A
Rationale: The woman who is not immune to rubella is immunized in the immediate postpartum period, because there is no danger of her being pregnant.