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 B

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. 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 8.

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. A score of 9 would 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).

A. reduces lochia B. promotes uterine involution C. improves pelvic floor tone D. alleviates perineal pain

Correct Answer is C

Explanation

A. Lochia is the normal postpartum vaginal discharge of blood and tissue, and its duration or volume is not affected by Kegel exercises.
B. Uterine involution ,the shrinking of the uterus to its pre-pregnancy size ,is a natural physiological process and is not influenced by Kegel exercises.
C. Kegel exercises specifically target the pelvic floor muscles, which may be weakened during pregnancy and childbirth. These exercises help strengthen the muscles, support pelvic organs, and prevent issues such as urinary incontinence.
D. While improved muscle tone may eventually support healing, these exercises are not a direct method for pain relief.

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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

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 B

Explanation

A nurse is teaching a postpartum client how to do muscle-clenching (Kegel) exercises for the perineum. The client asks the nurse, "Why do I need to do these exercises?" Which reason would the nurse most likely incorporate into the response?

Correct Answer is C

Explanation

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