Nokea
During ambulation to the bathroom, a postpartum client experiences a gush of dark red blood that soon stops. On data collection, a nurse finds the uterus to be firm, midline, and at the level of the umbilicus. Which of the following findings should the nurse interpret this data as being?
- A. Evidence of a possible vaginal hematoma
- B. An indication of a cervical or perineal laceration
- C. A normal postpartum discharge of lochia
- D. Abnormally excessive lochia rubra flow
Correct Answer: C
Rationale: The correct answer is C: A normal postpartum discharge of lochia. This finding indicates a normal postpartum process. Lochia is the vaginal discharge after childbirth consisting of blood, mucus, and uterine tissue. The gush of dark red blood followed by cessation is typical of lochia rubra, the initial stage of postpartum bleeding. The firm, midline, and well-positioned uterus indicates proper involution. Choices A and B are incorrect as the firm uterus rules out hematoma or laceration. Choice D is incorrect as the amount of bleeding described is within the normal range for postpartum lochia.
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A client has a new prescription for chlamydia. Which of the following statements should the nurse provide?
- A. This infection is treated with one dose of azithromycin.
- B. If your sexual partner has no symptoms, no medication is needed.
- C. You should avoid sexual relations for 3 days.
- D. You need to return in 6 months for retesting.
Correct Answer: A
Rationale: The correct answer is A because chlamydia is commonly treated with a single dose of azithromycin to ensure complete eradication of the infection. This antibiotic is highly effective against chlamydia. Option B is incorrect because both partners need treatment regardless of symptoms. Option C is incorrect as sexual abstinence for 7 days is recommended post-treatment. Option D is incorrect as retesting should be done after 3 months, not 6 months.
When assisting a client with breastfeeding, which of the following reflexes will promote the newborn to latch?
- A. Babinski
- B. Rooting
- C. Moro
- D. Stepping
Correct Answer: B
Rationale: The correct answer is B: Rooting. This reflex helps the newborn turn their head towards a stimulus, such as the mother's nipple, facilitating latching during breastfeeding. Babinski (A) is a reflex related to the sole of the foot, Moro (C) is a startle reflex, and Stepping (D) involves movements resembling walking. These reflexes do not directly support the latch during breastfeeding. Rooting reflex is the most relevant and essential reflex for successful breastfeeding initiation.
When reinforcing discharge teaching to the parents of a newborn regarding circumcision care, which statement made by a parent indicates an understanding of the teaching?
- A. The circumcision will heal within a couple of days.
- B. I should not remove the yellow mucus that will form.
- C. I will clean the penis with each diaper change.
- D. I will give him a tub bath within a couple of days.
Correct Answer: C
Rationale: The correct answer is C. Cleaning the penis with each diaper change is crucial for proper circumcision care to prevent infection. This statement shows understanding of the teaching as it emphasizes the importance of keeping the area clean.
A: The circumcision healing within a couple of days is incorrect as it usually takes about 1-2 weeks.
B: Not removing the yellow mucus can lead to infection, so this is an incorrect statement.
D: Giving a tub bath within a couple of days can increase the risk of infection, so this statement is incorrect.
When checking for the Moro reflex in a newborn, what action should the nurse take?
- A. Hold the newborn vertically under arms and allow one foot to touch the table.
- B. Stimulate the pads of the newborn's hands with stroking or massage.
- C. Stimulate the soles of the newborn's feet on the outer lateral surface of each foot.
- D. Hold the newborn in a semi-sitting position, then allow the newborn's head and trunk to fall backward.
Correct Answer: D
Rationale: The correct answer is D because the Moro reflex is elicited by sudden head movement or loud noise, causing the infant to extend their arms, then bring them back in a hugging motion. By holding the newborn in a semi-sitting position and allowing their head and trunk to fall backward, the nurse can observe the Moro reflex. Choices A, B, and C do not correctly elicit the Moro reflex as they involve different stimuli or movements that do not trigger the characteristic response of arm extension followed by flexion.
During Leopold maneuvers on a client in labor, which technique should be used by the nurse to identify the fetal lie?
- A. Apply palms of both hands to sides of the uterus
- B. Palpate the fundus of the uterus
- C. Grasp the lower uterine segment between thumb and fingers
- D. Stand facing the client's feet with fingertips outlining cephalic prominence
Correct Answer: B
Rationale: The correct answer is option B: Palpate the fundus of the uterus. This technique helps the nurse identify the fetal lie by feeling for the position of the baby's head or buttocks at the top of the uterus. By palpating the fundus, the nurse can determine whether the baby is in a vertex (head down) or breech (head up) position. This method is effective in assessing the fetal lie as it provides direct information about the baby's orientation within the uterus.
Option A is incorrect because applying palms to the sides of the uterus does not specifically help identify the fetal lie. Option C is incorrect as grasping the lower uterine segment does not provide information on the fetal lie. Option D is incorrect because standing facing the client's feet with fingertips outlining cephalic prominence is not a technique used to determine fetal lie.