A nurse is collecting data from the perineal pad of a client who is 3 days postpartum. The nurse last checked the perineal pad 1 hour ago. There is 2 cm of red lochia on the pad.
Which of the following correctly documents the nurse's finding?
Heavy lochia alba.
Heavy lochia rubra.
Moderate lochia serosa.
Scant lochia rubra.
The Correct Answer is D
Choice A rationale
Heavy lochia alba is an incorrect choice as lochia alba typically occurs after 10 days postpartum and is characterized by a whitish or yellowish discharge, not red.
Choice B rationale
Heavy lochia rubra is an incorrect choice because lochia rubra is characterized by bright red bleeding but heavy lochia would involve saturation of the pad within an hour, which is not the case here.
Choice C rationale
Moderate lochia serosa is incorrect because lochia serosa is typically pink or brown and occurs from approximately day 4 to day 10 postpartum, not red.
Choice D rationale
Scant lochia rubra is correct as the client is 3 days postpartum with red lochia measuring 2 cm on the pad, which indicates a small amount of bleeding consistent with scant lochia rubra.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Nonprescription medications can still have adverse effects on pregnancy and should be taken only with a healthcare provider's approval. This indicates a need for further teaching about safe medication use during pregnancy.
Choice B rationale
Reducing stress is beneficial during pregnancy and shows an understanding of healthy gestational changes. Stress management can positively impact maternal and fetal health.
Choice C rationale
Monitoring weight gain during pregnancy is important for maternal and fetal health. Appropriate weight gain supports healthy development and reduces the risk of complications.
Choice D rationale
Consulting with a doctor before using home remedies for nausea is a good practice. It ensures that the remedies are safe and appropriate for use during pregnancy.
Correct Answer is C
Explanation
Choice A rationale
An increase in serum bilirubin levels indicates worsening hyperbilirubinemia rather than improvement. Effective phototherapy should result in a decrease in bilirubin levels as it helps break down bilirubin into a form that can be excreted.
Choice B rationale
Hemoglobin and hematocrit levels are not directly affected by phototherapy. These values are more related to red blood cell count and do not indicate the effectiveness of phototherapy for treating hyperbilirubinemia.
Choice C rationale
A decrease in transcutaneous bilirubin (TcB) levels from 6 hours ago indicates effective phototherapy. Phototherapy reduces bilirubin levels in the blood by converting it to a water-soluble form that can be eliminated from the body.
Choice D rationale
Jaundice typically moves from the head to the lower body as bilirubin levels decrease. Movement from chest to groin level without a corresponding decrease in bilirubin levels does not necessarily indicate effective phototherapy. .
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