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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 pinkish brown, to creamy white.
Correct Answer: D
Rationale: The correct answer is D. Lochia normally lasts for about 21 days, and changes from a bright red, to pinkish brown, to creamy white. This is accurate information regarding the typical progression of lochia flow postpartum. Lochia rubra is the initial discharge, followed by lochia serosa, and finally, lochia alba. This teaching is important for the client to understand what to expect in terms of postpartum bleeding.
Choice A is incorrect as it inaccurately describes the color changes of lochia. Choice B is incorrect because the presence of numerous clots is common in the immediate postpartum period and not necessarily abnormal. Choice C is incorrect as perineal pad saturation is expected initially, and significant saturation may not always indicate hemorrhage.
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A client is admitted to the hospital with severe pregnancy-induced hypertension (PIH). The physician orders magnesium sulfate. Which nursing intervention is important when administering this drug?
- A. Assess blood pressure and respiratory rate every fifteen minutes
- B. Monitor blood glucose levels every eight hours
- C. Evaluate for orthostatic hypotension when getting the client up to walk
- D. Observe for premature labor every shift
Correct Answer: A
Rationale: The correct answer is A because magnesium sulfate is a central nervous system depressant used to prevent seizures in PIH. It can cause respiratory depression and hypotension. Assessing blood pressure and respiratory rate every fifteen minutes is crucial to monitor for signs of magnesium toxicity and ensure the client's safety. Monitoring blood glucose levels (B) is not directly related to magnesium sulfate administration. Evaluating for orthostatic hypotension (C) and observing for premature labor (D) are not specific to the administration of magnesium sulfate in treating PIH.
A nurse is performing a physical assessment of a newborn. Which of the following clinical findings should the nurse expect? (Select all that apply).
- A. Heart Rate 154/min
- B. Axillary temperature 96.8 F
- C. Respiratory rate 58/min
- D. Length 43 cm (16.9in)
Correct Answer: A,B,C,D
Rationale: The correct answer is A, B, C, and D.
1. Heart rate of 154/min is expected in a newborn, indicating normal cardiac function.
2. Axillary temperature of 96.8 F is within the normal range for a newborn.
3. Respiratory rate of 58/min is expected due to the newborn's immature respiratory system.
4. Length of 43 cm (16.9 in) falls within the normal range for a newborn's size.
Incorrect choices are not applicable due to lack of details, but in general, incorrect options would have included values outside the normal range for a newborn's physical assessment.
What is the main cause of mastitis in the postpartum client?
- A. Poor breastfeeding technique
- B. Inadequate hand washing
- C. Systemic maternal infection
- D. Prolonged nursing
Correct Answer: A
Rationale: The correct answer is A: Poor breastfeeding technique. Mastitis in postpartum clients is commonly caused by milk stasis due to inadequate milk removal, which can result from poor breastfeeding technique such as improper latch or infrequent feedings. This leads to inflammation and infection. Inadequate hand washing (B) is important for preventing infection but not the main cause of mastitis. Systemic maternal infection (C) may contribute but is not the primary cause. Prolonged nursing (D) can actually help prevent mastitis by promoting milk flow.
A 15-year-old client visits the clinic to get medical clearance to play a sport.
- A. "I will avoid showering at the gym."'
- B. "I can apply an antifungal cream daily."'
- C. "I should wear dark-colored socks."'
- D. "I should wear well-ventilated shoes."'
Correct Answer: D
Rationale: The correct answer is D: "I should wear well-ventilated shoes." This is because well-ventilated shoes help prevent fungal infections by keeping the feet dry and reducing moisture buildup, which is crucial for active individuals like athletes. Choice A is incorrect as avoiding showering at the gym is not a practical solution for preventing fungal infections. Choice B, applying antifungal cream daily, is reactive rather than preventive. Choice C, wearing dark-colored socks, does not directly address the issue of moisture and ventilation.
A labor and delivery nurse suspects that a client is in the transition stage of labor. Which information supports this conclusion? The client is:
- A. walking around the unit and talking with her partner.
- B. irritable and needs frequent repetition of directions.
- C. expelling feces and the fetal head is crowning.
- D. reading a magazine and talking on the phone.
Correct Answer: B
Rationale: The correct answer is B. In the transition stage of labor, the cervix dilates from 8 to 10 cm. This stage is characterized by intense contractions, increased irritability, and the need for frequent repetition of directions due to the intensity of labor pain. The client being irritable and needing frequent repetition of directions indicates that she is likely in the transition stage of labor.
A: Walking around and talking with her partner is more indicative of the early stage of labor.
C: Expelling feces and the fetal head crowning are more indicative of the second stage of labor.
D: Reading a magazine and talking on the phone are not typical behaviors during the transition stage of labor.