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. A score of 7 would be given if the infant’s heart rate was 100, but with less than optimal responses for color, muscle tone, and respiratory effort. However, this baby demonstrates strong responses in all categories.

B. A score of 8would indicate that the baby has no signs of cyanosis and perfect responses in all categories, but since the infant has blue hands, it scores slightly lower (1 point less for color).

C. A score of 5 would indicate more significant distress, with poor color, respiratory effort, and muscle tone. This infant is showing good signs of adaptation.

D. The Apgar score is calculated based on five criteria: heart rate, respiratory effort, muscle tone, reflex irritability, and color. The infant in the scenario has:Heart rate of 100 (score 2)Pink body and blue hands (score 1 for color—because the baby is not fully pink, indicating some cyanosis in the extremities)Active motion (score 2 for muscle tone)Strong lusty cry (score 2 for reflex irritability/responsiveness to stimuli)
Good respirations (score 2)Adding these scores (2 + 1 + 2 + 2 + 2), the total is 9.

A. Have her blood checked every month for the next 360 days. B. Receive Rhogam with the next pregnancy C. Seek genetic counselling with her partner before the next pregnancy D. Becoming pregnant within the year

Correct Answer is A

Explanation

A. Have her blood checked every month for the next 360 days is correct. After a molar pregnancy (also known as a hydatidiform mole), the client must have serial monitoring of hCG levels (usually monthly for 6 to 12 months) to ensure that all molar tissue has been removed and that gestational trophoblastic disease (such as choriocarcinoma) does not develop. A rising or persistently elevated hCG level can indicate malignancy.

B. Receive Rhogam with the next pregnancy may be necessary if the client is Rh-negative, but it is not specific or essential to the follow-up care for a molar pregnancy itself.

C. Seek genetic counselling with her partner before the next pregnancy is not routinely required after a molar pregnancy unless there’s a history of recurrent molar pregnancies or other genetic concerns.

D. Becoming pregnant within the year is discouraged. Pregnancy should be avoided for at least 6 to 12 months after molar pregnancy to allow for monitoring of hCG levels without interference from a new pregnancy, which could complicate interpretation of results.

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

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Naxlex Comprehensive Predictor Exams

The nurse is performing an Apgar score on a newborn at 5 minutes after birth. The infant has a heart rate of 100, pink body and blue hands, active motion, and a strong lust cry and respirations. What is the Apgar score that should be assigned to this infant?

Correct Answer is D

Explanation

The nurse is giving discharge instructions to the client following evacuation of the molar pregnancy. Which of the following information should the nurse ascertain that the client understands?

Correct Answer is A

Explanation

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