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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A) Incorrect - The umbilical area is not a typical location for auscultating fetal heart tones.
B) Incorrect - The suprapubic area is not a common location for auscultating fetal heart tones.
C) Correct - At 12 weeks of gestation, the nurse would typically auscultate the fetal heart tones above the left iliac crest, which is in the lower abdomen. This is where the uterus is located at this stage of pregnancy.
D) Incorrect - Auscultating below the liver border on the right abdomen is not a standard practice for fetal heart tone assessment.
Correct Answer is C
Explanation
A) Incorrect- The water heater temperature should be set to 49.4°C (120°F) or below to prevent scalding. The given temperature is slightly too high.
B) Incorrect- Soft bumper pads in cribs can pose a suffocation risk and are not recommended.
C) Correct - Washing the newborn's face with a warm, soapy washcloth is a safe way to cleanse the baby's face. Harsh chemicals or strong soaps should be avoided.
D) Incorrect- Pillows should not be placed under a newborn's head during naps to reduce the risk of suffocation. The baby's sleep environment should be free of soft bedding.
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