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 C
Explanation
Choice A rationale
2 units is insufficient to bring down a blood sugar level of 152 mg/dL adequately. According to the sliding scale, 2 units typically lower blood sugar by 50-60 mg/dL, which might not be enough for this level.
Choice B rationale
3 units might reduce blood sugar by approximately 75-90 mg/dL. However, this reduction may not be adequate to bring the blood sugar level within the target range, depending on individual response to insulin.
Choice C rationale
4 units of insulin are suitable for a blood sugar level of 152 mg/dL. Generally, 1 unit of insulin lowers blood sugar by 30-50 mg/dL. Administering 4 units should ideally lower the blood sugar level to the desired range.
Choice D rationale
5 units of insulin could result in an excessive drop in blood sugar levels. It could reduce the blood sugar level by 150-200 mg/dL, which might risk hypoglycemia, making it an unsuitable choice for a blood sugar level of 152 mg/dL.
Correct Answer is B
Explanation
Choice A rationale
Platelet aggregation is associated with the formation of blood clots, which may contribute to complications like stroke but is not the primary cause of the client's symptoms of blurred vision and cognitive impairment in preeclampsia.
Choice B rationale
Autoregulation dysfunction of the cerebral vasculature causes increased cerebral blood flow and edema, leading to neurological symptoms such as blurred vision and impaired cognitive function. This dysfunction is a primary factor in the pathophysiology of preeclampsia with severe features.
Choice C rationale
Oxidative stress and inflammatory response contribute to endothelial dysfunction in preeclampsia but are not directly responsible for the neurological symptoms described. These factors play a broader role in the progression of the disease.
Choice D rationale
Uteroplacental ischemia affects the placenta and fetal environment, contributing to fetal growth restriction and distress but does not directly cause neurological symptoms like blurred vision in the mother.
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