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The nurse has completed a postpartum assessment on a patient who delivered 1 hour ago. Which amount of lochia consists of a moderate amount?
- A. Saturated peripad
- B. 10 to 15 cm (4- to 6-inch) stain on the peripad
- C. 2.5 to 10 cm (1- to 4-inch) stain on the peripad
- D. Less than a 1-inch stain on the peripad
Correct Answer: B
Rationale: The correct answer is B (10 to 15 cm (4- to 6-inch) stain on the peripad) because a moderate amount of lochia typically indicates a blood stain of 10 to 15 cm within 1 hour postpartum. This amount of lochia signifies a normal postpartum bleeding pattern.
Incorrect answers:
A: Saturated peripad indicates a heavy amount of lochia, not moderate.
C: 2.5 to 10 cm (1- to 4-inch) stain on the peripad is considered light, not moderate.
D: Less than a 1-inch stain on the peripad is minimal lochia, not moderate.
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A woman has just had a low forceps delivery. For which of the following should the nurse assess the woman during the immediate postpartum period?
- A. Infection.
- B. Bloody urine.
- C. Heavy lochia.
- D. Rectal abrasions.
Correct Answer: C
Rationale: Heavy lochia indicates potential hemorrhage.
A nurse is assessing a 1-day postpartum client who had a spontaneous vaginal delivery over an intact perineum. The fundus is firm at the umbilicus, lochia moderate, and perineum edematous. One hour after receiving ibuprofen 600 mg po, the client is complaining of perineal pain at level 9 on a 10-point scale. Based on this information, which of the following is an appropriate conclusion for the nurse to make about the client?
- A. She should be assessed by her doctor.
- B. She should have a sitz bath.
- C. She may have a hidden laceration.
- D. She needs a narcotic analgesic.
Correct Answer: C
Rationale: Hidden lacerations can cause severe pain.
The nurse is about to elicit the Moro reflex. Which of the following responses should the nurse expect to see?
- A. When the cheek of the baby is touched
- B. the newborn turns toward the side that is touched.
- C. When the lateral aspect of the sole of the baby's foot is stroked
- D. the toes extend and fan outward.
Correct Answer: C
Rationale: Moro reflex involves extension of arms and flexion of knees in response to a sudden stimulus.
A 2-day-old breastfeeding baby born via normal spontaneous vaginal delivery has just been weighed in the newborn nursery. The nurse determines that the baby has lost 3.5% of the birth weight. Which of the following nursing actions is appropriate?
- A. Do nothing because this is a normal weight loss.
- B. Notify the neonatologist of the significant weight loss.
- C. Advise the mother to bottle feed the baby at the next feed.
- D. Assess the baby for hypoglycemia with a glucose monitor.
Correct Answer: A
Rationale: Weight loss up to 7-10% is considered normal in the first few days due to fluid loss; 3.5% does not warrant immediate intervention.
The nurse is caring for a birth mother who is relinquishing her newborn. What intervention is appropriate for the nurse?
- A. Use words like “giving away your child” or “giving up for adoption.”
- B. Tell the person not to hold the baby.
- C. Ask the person why she is giving up her baby.
- D. Ask about the patient’s expectations for having newborn photos or video.
Correct Answer: D
Rationale: The correct answer is D because asking about the patient's expectations for newborn photos or video shows empathy and support for the mother's emotional needs during this difficult time. It allows the nurse to provide personalized care and helps the mother create lasting memories.
A: Using phrases like "giving away your child" is insensitive and can be hurtful to the mother.
B: Discouraging the mother from holding the baby can be emotionally damaging and is not supportive.
C: Asking why she is giving up her baby can be intrusive and may not be helpful at this moment.