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

Answer and Explanation

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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Correct Answer is A

Explanation

A) Correct- Feeling the baby's swallowing during breastfeeding indicates that the baby is effectively transferring milk from the breast. It suggests that the baby is latched on correctly and is receiving milk.
B) Incorrect- Moderate tenderness during breastfeeding is common initially, but it should not be persistent or severe.
C) Incorrect- While bowel movements are important, having at least one bowel movement every day is not necessarily an indicator of effective breastfeeding.
D) Incorrect- While wet diapers are important to ensure adequate hydration, having at least six wet diapers every day is not the primary sign of effective breastfeeding.

A. Notify the provider. B. Administer a prescribed analgesic C. Assist the client to empty her bladder. D. Monitor perineal pads for clots.

Correct Answer is C

Explanation

A) Incorrect- While notifying the provider might be necessary, addressing bladder distention takes precedence in this scenario.
B) Incorrect- Administering an analgesic might be indicated for pain relief, but addressing bladder distention is the priority.
C) Correct - Assisting the client to empty her bladder is the first action to take. A full bladder can prevent the uterus from contracting properly and can lead to excessive bleeding.
D) Incorrect- Monitoring perineal pads for clots is important but not the first action to take when bladder distention is present.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse in a clinic is reinforcing teaching about signs of effective breastfeeding with a client who has a 5-day-old newborn. Which of the following statements by the client demonstrates an understanding of the teaching?

Correct Answer is A

Explanation

A nurse is caring for a client who had a vaginal delivery 1 day ago. The nurse determines that the client's fundus is firm, located 2 fingerbreadths above the umbilicus, and deviated to the left. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

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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?