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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason: Taking the newborn to the nursery for the initial assessment. This is an ineffective intervention that disrupts parental atachment by separating the mother and the newborn. It also deprives the newborn of the benefits of skin to skin contact and breastfeeding.
Choice B Reason: Allowing the mother a chance to rest without the baby immediately after delivery. This is an unnecessary intervention that delays parental atachment by postponing the first contact between the mother and the newborn. It also ignores the mother's desire and readiness to hold and feed her baby.
Choice C Reason: Placing the newborn under a radiant warmer to do the initial assessment. This is an outdated intervention that hinders parental atachment by creating a physical barrier between the mother and the newborn. It also exposes the newborn to potential risks such as dehydration, hyperthermia, or eye damage.
Choice D Reason: Placing the newborn on the maternal abdomen and doing the initial assessment. This is because this intervention facilitates skin to skin contact, eye contact, and bonding between the mother and the newborn. It also enhances breastfeeding initiation, thermoregulation, and maternal-infant atachment.
Correct Answer is A
Explanation
Choice A Reason: Macrosomic fetus is a fetus that weighs more than 4000 grams or 8 pounds 13 ounces at birth. It is not a common complication of teenage pregnancy, but rather of maternal diabetes, obesity, or a history of large babies.
Choice B Reason: Preeclampsia is a condition characterized by high blood pressure and proteinuria in pregnancy. It can cause serious complications for both the mother and the baby, such as seizures, organ damage, growth restriction, and placental abruption. Teenage pregnancy is a risk factor for preeclampsia, especially if the mother is younger than 15 years old.
Choice C Reason: Inadequate nutritional status of mother is a condition where the mother does not consume enough calories, protein, vitamins, minerals, or fluids during pregnancy. It can affect the growth and development of the baby and increase the risk of low birth weight, preterm birth, and birth defects. Teenage pregnancy is a risk factor for inadequate nutritional status of mother, as teenagers may have poor dietary habits, eating disorders, or limited access to food.
Choice D Reason: Cephalopelvic disproportion is a condition where the size or shape of the baby's head or body is too large to fit through the mother's pelvis. It can prevent normal vaginal delivery and require cesarean section. Teenage pregnancy is a risk factor for cephalopelvic disproportion, as teenagers may have smaller or immature pelvises that are not fully developed.
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