A nurse on a postpartum unit is caring for a client who delivered vaginally 24 hr ago.
Which of the following should the nurse expect to find when collecting data?
Moderate lochia serosa on perineal pads
Frequent urges to urinate
Uterine fundus 2 finger widths above the umbilicus
colostrum expressed from the breast
The Correct Answer is A
A) Correct - Lochia serosa, a pinkish-brown vaginal discharge, is typically present 24 hours after vaginal delivery. It is the second stage of lochia that follows the bright red lochia rubra.
B) Incorrect- Frequent urges to urinate might be present but are not specific to the 24- hour postpartum period.
C) Incorrect- The uterine fundus should be descending in the days after childbirth, not located 2 finger widths above the umbilicus.
D) Incorrect- Colostrum is the early milk produced by the breasts, but its presence is not a specific finding in the immediate postpartum period.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A) Incorrect- Methylergonovine is used to treat postpartum hemorrhage due to uterine atony, not hypotension.
B) Incorrect- Emptying the client's bladder can help improve blood pressure but is not the priority over treating hypotension.
C) Incorrect- The knee-chest position might be used to increase blood pressure, but it is not the first-line intervention in this situation.
D) Correct - A bolus of lactated Ringers or another appropriate intravenous
Correct Answer is B
Explanation
A) Incorrect- A 20-gauge needle is too large and could cause unnecessary pain for the newborn.
B) Correct - Choosing a 3/8-inch needle is appropriate for administering vaccines to newborns. he hepatitis B vaccine is given intramuscularly in the anterolateral thigh of newborns. The needle size should be appropriate for the muscle mass and age of the infant. A 3/8-inch needle is recommended for newborns, while a 20-gauge needle is too large and may cause tissue damage.
C) Incorrect- Administering the vaccine into the dorsal gluteal muscle is not recommended because of the risk of injury to the sciatic nerve; the recommended site is the vastus lateralis muscle in the anterolateral thigh.
D) Incorrect- The hepatitis B vaccine is usually administered in a dose of 0.5 mL for newborns, but this is not the only action that the nurse should take.
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