A nurse is completing a postpartum assessment. Which finding would alert the nurse to a potential problem?

temperature of 101° F (38.3° C)

respiratory rate of 16 breaths per minute

lochia rubra with a fleshy odor

pain rating of 2 on a scale from 0 to 10

Answer and Explanation

The Correct Answer is A

A. Temperature of 101° F (38.3° C) is concerning as it may indicate an infection, especially if it persists beyond the first 24 hours postpartum. A mild increase in temperature can be common during the first 24 hours after birth due to the physical stress of labor and delivery, but a temperature of 101° F is above the normal postpartum range and warrants further investigation for possible infection, such as endometritis or a urinary tract infection.

B. Respiratory rate of 16 breaths per minute is within the normal range for a postpartum woman, as normal respiratory rate is typically between 12 and 20 breaths per minute in adults. No immediate concerns are suggested by this finding.

C. Lochia rubra with a fleshy odor is a normal finding during the first few days postpartum. Lochia rubra, the initial discharge after childbirth, typically has a fleshy or musty odor and contains blood, mucus, and tissue from the uterine lining. A foul or offensive odor, however, would be indicative of infection, but a "fleshy" odor is normal.

D. Pain rating of 2 on a scale from 0 to 10 is within an acceptable range for postpartum pain. Mild discomfort is expected, especially around the perineum or from uterine contractions, and can usually be managed with over-the-counter pain relievers. A pain level of 2 suggests that the patient is coping well.

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Correct Answer is D

Explanation

A. "I need to call my doctor if my temperature increases." This is an appropriate and accurate statement. An elevated temperature could be a sign of infection, which is a risk for women with preterm prelabor rupture of membranes (PPROM). The woman should contact her healthcare provider if her temperature rises, as infection can lead to complications.

B. "I can shower, but I shouldn't take a tub bath." This is also correct. After PPROM, the woman is typically allowed to shower to maintain personal hygiene, but taking a tub bath can increase the risk of infection by allowing bacteria to enter the vagina.

C. "I need to keep a close eye on how active my baby is each day." This is a correct and helpful statement. Monitoring fetal movement is important for assessing the baby's well-being. Decreased fetal movement could indicate a potential problem, and the woman should contact her provider if she notices reduced activity.

D. "It's okay for my husband and me to have sexual intercourse." This statement indicates a need for additional teaching. Sexual intercourse is typically not recommended after PPROM because it could increase the risk of infection, especially if the membranes are ruptured. The woman should avoid sexual activity until advised otherwise by her healthcare provider.

A. dark red vaginal bleeding B. absence of pain C. insidious onset D. absent fetal heart tones

Correct Answer is ["A","D"]

Explanation

A. Dark red vaginal bleeding is often seen in placental abruption. The blood from an abruption is typically dark red (indicating that it is older blood) and may be mixed with amniotic fluid, making it more challenging to assess. However, the bleeding can sometimes be concealed, especially in complete abruption or retroplacental hemorrhage, where blood accumulates behind the placenta.

B. Absence of pain is incorrect. In fact, placental abruption is typically associated with abdominal pain, which can be severe and often comes on suddenly. Pain occurs due to the detachment of the placenta from the uterine wall and subsequent irritation or bleeding into the uterine cavity.

C. Insidious onset is incorrect. Placental abruption usually has a sudden or acute onset of symptoms, such as vaginal bleeding and abdominal pain. An insidious onset would be more suggestive of other conditions, such as placenta previa.

D. Absent fetal heart tones is a critical finding. Placental abruption can cause fetal distress or fetal death, especially if the abruption is severe. Absent fetal heart tones are a sign of fetal compromise or death resulting from the disruption of placental blood flow.

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A nurse is completing a postpartum assessment. Which finding would alert the nurse to a potential problem?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a pregnant woman with preterm prelabor rupture of membranes about caring for herself after she is discharged home (which is to occur later this day). Which statement by the woman indicates a need for additional teaching?

Correct Answer is D

Explanation

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Correct Answer is ["A","D"]

Explanation

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