A new mother of a newborn girl calls the clinic in a panic, concerned about the blood-tinged soiled diaper. What is the best response from the nurse?

This can be from the sudden withdrawal of your hormones. It's not a cause for alarm.

The baby may have a problem; let's schedule an appointment.

For now, just watch her. If this continues, call us back.

This can be related to cleaning her perineal area; be more careful.

Answer and Explanation

The Correct Answer is A

This can be from the sudden withdrawal of your hormones. It's not a cause for alarm. This is because newborn female babies may have a little bloody vaginal discharge in their diaper due to the withdrawal of maternal hormones after delivery. This usually stops as the hormones return to normal levels¹².

Choice B is wrong because the baby does not need an appointment for this condition.

Choice C is wrong because the mother does not need to watch her baby for this condition.

Choice D is wrong because the blood is not related to cleaning her perineal area.

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Correct Answer is B

Explanation

Your baby can lose 5% of body weight during the first 3 days of life. This is a normal physiological process that happens as your baby adjusts to breastfeeding and expels excess fluids. Your baby should regain this weight by 10 to 14 days of age.

Choice A is incorrect because your baby does not need to feed constantly in the first week of life. Your baby should feed at least eight times in 24 hours but may have periods of cluster feeding where they feed more frequently for a few hours.

Choice C is incorrect because your baby should have more than 5 wet diapers per day after the fourth day of life. This is a sign that your baby is getting enough milk and is well-hydrated.

Choice D is incorrect because your baby should gain more than 0.25 oz (7 grams) per day after the fourth day of life. The average weight gain for a breastfed baby is about 0.5 to 1 oz (14 to 28 grams) per day in the first month.

A. Increase the rate of IV fluids. B. Assist the client to ambulate. C. Perform fundal massage. D. Check for blood under the client's buttock.

Correct Answer is D

Explanation

Check for blood under the client's buttock. This is because lochia rubra is the normal vaginal discharge that occurs after childbirth, consisting of blood, mucus, and tissue from the placenta and the uterus lining. It is usually heavy for the first three to four days and can pool under the client's buttocks if they are lying down. Checking for blood under the buttock can help assess the amount of bleeding and prevent complications such as infection or hemorrhage.

The other choices are not correct for the following reasons:

A. Increasing the rate of the IV fluids is not necessary because the client's fundus is firm and midline, indicating that the uterus is contracting well and preventing excessive bleeding.

B. Assisting the client to ambulate is not advisable because it can increase the lochia flow and cause fainting or dizziness due to blood loss.

C. Performing fundal massage is not indicated because the fundus is already firm and midline, meaning that the uterus is adequately contracted. Massaging a firm fundus can cause pain and discomfort to the client.

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A new mother of a newborn girl calls the clinic in a panic, concerned about the blood-tinged soiled diaper. What is the best response from the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a new mother about signs of effective breastfeeding of her newborn. Which of the following information should the nurse include in the teaching?

Correct Answer is B

Explanation

A nurse is caring for a client who is 4 hr postpartum. The nurse finds a small amount of lochia rubra on the client's perineal pad. The fundus is midline and firm at the umbilicus. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

The nurse assesses a boggy uterus with the fundus above the umbilicus and deviated to the side. The nurse should next assess:

A nurse is collecting data from a client who is 12 hr postpartum. Which of the following findings should the nurse expect?

Five days after a spontaneous vaginal delivery, a woman comes to the emergency room because she has a fever and persistent cramping. The nurse recognizes that the cause of these signs and symptoms may be:

To prevent possible retinopathy in a preterm infant requiring oxygen therapy, the nurse will:

The nurse assesses a postpartum woman's perineum and notices that her lochial discharge is moderate in amount and red. The nurse would record this as what type of lochia?

A nurse is reviewing the medical record of a client who experienced a vaginal birth 2 hr ago. The nurse should identify which of the following findings places the client at risk for a postpartum hemorrhage.

The nurse is conducting a prenatal class explaining the various activities that will occur within the first few hours after birth. The nurse determines the session is successful when the couples correctly choose which reason for the use of an antibiotic ointment.