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 D
Explanation
Choice A rationale
A hymenal tag and white discharge on the genitalia are normal findings in newborn females, often due to maternal hormone exposure.
Choice B rationale
Edema on the scalp that crosses suture lines, known as caput succedaneum, is common and typically resolves on its own without intervention.
Choice C rationale
A heart murmur in a newborn can be normal, as many murmurs are benign and resolve as the newborn's circulation adjusts post-birth.
Choice D rationale
A large, deep sacral dimple above the gluteal cleft can be an indication of underlying spinal abnormalities, such as spina bifida, and requires further evaluation.
Correct Answer is B
Explanation
Choice A rationale
Gestational hypertension is diagnosed when high blood pressure develops after 20 weeks of pregnancy without other symptoms of preeclampsia, such as proteinuria or end-organ dysfunction.
Choice B rationale
Preeclampsia with severe features includes high blood pressure, proteinuria, and symptoms like blurred vision and headaches. These indicate severe disease, which can endanger both the mother and the fetus if left untreated.
Choice C rationale
Preeclampsia without severe features involves high blood pressure and proteinuria but without the additional severe symptoms like blurred vision and headache.
Choice D rationale
Chronic hypertension refers to high blood pressure that was present before pregnancy or diagnosed before 20 weeks of gestation. It does not typically present with acute symptoms like blurred vision and headache that develop suddenly.
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