When the nurse is assessing a postpartum client approximately 6 hours after delivery, which finding would warrant further investigation?
Select one:

Moderate amounts of deep red lochia.

Sweating while afebrile.

Voiding 350 mL of blood-tinged urine.

Heart rate of 115 beats/minute.

Answer and Explanation

The Correct Answer is D

Choice A Reason: Moderate amounts of deep red lochia. This is not a finding that would warrant further investigation, but rather a normal finding for the early postpartum period. Lochia is the vaginal discharge that occurs after delivery, which consists of blood, mucus, and tissue from the uterus. Lochia is usually deep red in color and moderate in amount for the first few days after delivery.

Choice B Reason: Sweating while afebrile. This is not a finding that would warrant further investigation, but rather a common occurrence in the postpartum period. Sweating is a mechanism of thermoregulation that helps the body eliminate excess ﬂuid and electrolytes that were retained during pregnancy. Sweating does not necessarily indicate fever or infection.

Choice C Reason: Voiding 350 mL of blood-tinged urine. This is not a finding that would warrant further investigation, but rather an expected outcome for the postpartum period. Voiding large amounts of urine is normal in the postpartum period, as the body eliminates the excess ﬂuid that was accumulated during pregnancy. Blood-tinged urine may be due to trauma or irritation of the urinary tract during labor or delivery, which usually resolves within a few days.

Choice D Reason: Heart rate of 115 beats/minute. This is because a heart rate of 115 beats/minute is higher than the normal range for an adult, which is 60 to 100 beats/minute. A high heart rate may indicate postpartum hemorrhage, infection, pain, anxiety, or dehydration. The nurse should further assess the client for other signs and symptoms of these conditions and notify the physician if necessary.

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Correct Answer is A

Explanation

Choice A Reason: "Our baby's newborn rash is from this syndrome." This is because this statement by a parent indicates that additional teaching is required, as it shows a misunderstanding or confusion about FAS and its manifestations. FAS is a condition that occurs when a woman consumes alcohol during pregnancy, which can aﬀect the development and function of various organs and systems in the fetus and child. FAS can cause physical, behavioral, and cognitive problems such as facial abnormalities, growth retardation, learning difficulties, and atention deficits. FAS does not cause newborn rash, which is a common and benign condition that aﬀects many newborns regardless of maternal alcohol intake. Newborn rash is also known as erythema toxicum neonatorum or baby acne, which is characterized by small red bumps or pustules on the face, chest, or back that usually disappear within a few weeks.

Choice B Reason: "His face looks like it does due to this problem." This is a correct answer that indicates adequate understanding of FAS and its features. Facial abnormalities are one of the characteristic signs of FAS, which include small eye openings, thin upper lip, ﬂat nasal bridge, and smooth philtrum (the groove between the nose and upper lip).

Choice C Reason: "He can show signs of withdrawal from alcohol exposure like jiteriness, sweating, hyper reﬂexes, poor feeding and not sleeping well." This is a correct answer that indicates adequate understanding of FAS and its complications. Signs of withdrawal are possible eﬀects of FAS, which occur when the fetus or newborn is exposed to alcohol in utero or through breast milk, which can cause neurotoxicity and dependency. Signs of withdrawal can include jiteriness, sweating, hyper reﬂexes, poor feeding, and not sleeping well, as well as irritability, seizures, or tremors.

Choice D Reason: "He is at risk of having intellectual disabilities, so we will need to get extra services to support him." This is a correct answer that indicates adequate understanding of FAS and its implications. Intellectual disabilities are potential outcomes of FAS, which aﬀect the cognitive development and function of the child. Intellectual disabilities can cause problems with memory, Reasoning, language, and social skills. Extra services and support may be needed to help the child achieve their optimal potential and quality of life.

A. Latent phase of the first stage of labor. B. Transition phase of the first stage of labor. C. Perineal phase of the second stage of labor. D. Active phase of the first stage of labor.

Correct Answer is A

Explanation

Choice A Reason: Latent phase of the first stage of labor. This is because this phase is characterized by mild and irregular contractions, slow cervical dilation (up to 4 cm), minimal cervical eﬀacement (up to 40%), and minimal discomfort or pain. The latent phase is also known as the early phase or preparatory phase of labor.

Choice B Reason: Transition phase of the first stage of labor. This is an incorrect answer that describes a diﬀerent phase with diﬀerent characteristics. The transition phase is marked by strong and frequent contractions, rapid cervical dilation (from 8 to 10 cm), complete cervical eﬀacement (100%), and intense discomfort or pain. The transition phase is also known as the terminal phase or acceleration phase of labor.

Choice C Reason: Perineal phase of the second stage of labor. This is an incorrect answer that refers to another stage and phase with diﬀerent features. The second stage of labor begins with complete cervical dilation (10 cm) and ends with delivery of the baby. The perineal phase is the last part of the second stage, where the baby's head crowns and emerges through the vaginal opening.

Choice D Reason: Active phase of the first stage of labor. This is an incorrect answer that indicates another phase with diﬀerent atributes. The active phase is characterized by moderate and regular contractions, progressive cervical dilation (from 4 to 8 cm), increased cervical eﬀacement (from 40% to 80%), and increased discomfort or pain. The active phase is also known as the middle phase or dilatation phase of labor.

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When the nurse is assessing a postpartum client approximately 6 hours after delivery, which finding would warrant further investigation? Select one:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Parents have been told their child has fetal alcohol syndrome (FAS). Which statement by a parent indicates that additional teaching is required? Select one:

Correct Answer is A

Explanation

Assessment of a woman in labor reveals cervical dilation of 3 cm, cervical eﬀacement of 30%, and contractions occurring every 8 to 10 minutes, lasting about 30 seconds. The nurse determines that this client is in: Select one:

Correct Answer is A

Explanation

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In caring for the premature infant, the nurse must continually assess hydration status. Parameters to assess would include all of the following except: Select one:

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When the nurse is assessing a postpartum client approximately 6 hours after delivery, which finding would warrant further investigation?
Select one: