A nurse is collecting data from a client who is 20 hr postpartum following a vaginal delivery. Which of the following findings should the nurse expect?
Positive Homans' sign
Full, firm breasts
Firm fundus at midline
Lochia serosa
The Correct Answer is C
A. Homans' sign is a test for deep vein thrombosis and is not a normal postpartum finding.
B. Full, firm breasts typically occur a few days after delivery when milk production begins, not at 20 hours postpartum.
C. A firm fundus at the midline is an expected finding in the immediate postpartum period, indicating that the uterus is contracting and involuting properly.
D. Lochia serosa (pinkish-brown discharge) is a normal finding around 3 to 10 days postpartum, but it is not typically present at 20 hours postpartum.
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Related Questions
Correct Answer is D
Explanation
A: Using a plastic cover on the crib mattress can lead to overheating and discomfort for the baby. It is not recommended.
B: Bumper pads pose a suffocation and entrapment risk for infants. They should not be used in the crib.
C: Placing a newborn on a foam-wedge cushion can increase the risk of suffocation. Infants should be placed on their backs on a firm mattress without any extra padding.
D: Ensuring that the mattress fits snugly against the sides of the crib prevents any gaps where the baby could become trapped. This is an important safety measure.
Correct Answer is A
Explanation
A. 2+ ketonuria indicates an elevated level of ketones in the urine, which can be a sign of inadequate nutrition or metabolism. This should be reported to the provider for further evaluation.
B. A urine specific gravity of 1.030 is within normal range during pregnancy.
C. A hematocrit (Hct) of 38% is within the normal range for a pregnant individual.
D. A fasting blood glucose level of 70 mg/dL is within the normal range.
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