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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Correct Answer is D
Explanation
A. Uterine atony
Uterine atony refers to the lack of muscle tone in the uterus after delivery, leading to excessive bleeding. This is not typically associated with abruptio placentae, which involves the premature separation of the placenta from the uterine wall during pregnancy, typically presenting with different symptoms such as painful contractions and bleeding.
B. Polyhydramnios
Polyhydramnios refers to an excessive amount of amniotic fluid during pregnancy and is not a characteristic of abruptio placentae. Polyhydramnios can be associated with various conditions but is not directly linked to placental abruption.
C. Painless vaginal bleeding
Painless vaginal bleeding is more characteristic of placenta previa, a condition where the placenta is abnormally positioned over the cervix. Abruptio placentae, on the other hand, typically presents with painful vaginal bleeding due to the detachment of the placenta from the uterine wall.
D. Board-like abdomen
A board-like abdomen is a classic sign of abruptio placentae, indicating significant uterine muscle contraction and possible internal hemorrhage. The sudden separation of the placenta can cause blood to accumulate behind the placenta, leading to a rigid, "board-like" feeling of the abdomen, which is a hallmark symptom of this condition.
Correct Answer is A
Explanation
A. Yogurt is a good source of calcium and is a suitable recommendation for a client with a low calcium level during pregnancy.
B. Long-grain rice is not particularly high in calcium.
C. Avocados are a healthy food but are not a significant source of calcium.
D. Peanut butter is not a significant source of calcium.
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