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 longitudinal fetal lie, where the baby is aligned vertically with the mother’s spine, is the normal and optimal position for labor. It typically does not cause prolonged or difficult labor.
Choice B rationale
A gynecoid pelvis is considered the most favorable pelvic shape for vaginal delivery. It is roomy and allows for the easiest passage of the baby through the birth canal, reducing the likelihood of prolonged labor.
Choice C rationale
General flexion, where the baby’s chin is tucked to its chest and the limbs are flexed, is the optimal fetal attitude for birth. This position facilitates a smoother and shorter labor process.
Choice D rationale
Persistent occiput posterior (OP) position, where the baby’s head is down but facing the mother’s front, can result in a difficult and prolonged labor. This position often leads to severe back pain for the mother and may complicate the labor process.
Correct Answer is C
Explanation
Choice A rationale
Obtaining a set of vital signs is important but not the first action. Assessing responsiveness and activating emergency response takes precedence to ensure prompt intervention.
Choice B rationale
Assessing vaginal bleeding is necessary, but it should follow immediate life-saving actions like calling the rapid response team.
Choice C rationale
Calling the rapid response team should be the first action as it mobilizes a team of healthcare professionals to provide immediate advanced care, which is crucial in an unresponsive patient.
Choice D rationale
Notifying the provider is essential, but it should be done after the rapid response team is activated to ensure timely intervention.
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