A nurse is caring for a 32-year-old female client who is 2 days postpartum in the postpartum unit.

Exhibits

For each potential client finding, click to specify if the finding is expected or unexpected.

White blood cell count

Blood clot size

Uterine findings

Lochia findings

Calf findings

Blood pressure

Answer and Explanation

The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"}}

White blood cell count: Expected—mild leukocytosis is normal postpartum due to physiological stress.
Blood clot size: Expected—small clots, like a pea-sized clot, are common and not concerning unless excessive bleeding occurs.
Uterine findings: Expected—firm and midline uterus indicating effective involution.
Lochia findings: Expected—progressing normally without signs of infection (no foul odor).
Calf findings: Expected—a single varicose vein without tenderness or swelling is not concerning.
Blood pressure: Expected—within normal postpartum range.

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Correct Answer is A

Explanation

Choice A rationale

In the immediate postpartum period, it is normal to observe lochia rubra, which is a dark red discharge, and the passage of small blood clots. A firm, midline fundus at the umbilicus indicates that the uterus is contracting effectively to control bleeding. Given these expected findings within the first hour postpartum, continued monitoring is the appropriate initial action.

Choice B rationale

Notifying the provider is usually indicated when there are deviations from the expected postpartum findings, such as excessive bleeding, a boggy uterus, or signs of infection. The current assessment does not indicate such complications.

Choice C rationale

Encouraging the client to empty her bladder is important in the postpartum period as a full bladder can interfere with uterine contraction and lead to increased bleeding. However, with a firm, midline fundus and expected lochia, this is not the priority action over continued monitoring.

Choice D rationale

Increasing the frequency of fundal massage is indicated when the uterus is boggy or not contracting effectively, leading to increased bleeding. The client's fundus is already firm, so increasing massage is not the immediate priority.

A. Reactive Non-stress test. B. Non-reactive Non-stress test. C. Negative Non-stress test. D. Positive Non-stress test.

Correct Answer is A

Explanation

Choice A rationale

A reactive non-stress test indicates fetal well-being. The criteria for a reactive NST in a fetus greater than 32 weeks gestation include two or more fetal heart rate accelerations of at least 15 beats per minute above the baseline lasting for at least 15 seconds within a 20-minute period. The baseline fetal heart rate should be within the normal range of 110 to 160 beats per minute. This client's results meet these criteria.

Choice B rationale

A non-reactive non-stress test lacks the required number of fetal heart rate accelerations or the accelerations do not meet the amplitude or duration criteria within the specified time frame. This suggests the fetus may be experiencing some form of stress and requires further evaluation.

Choice C rationale

A negative non-stress test is not a standard term used to describe NST results. The test is categorized as either reactive (indicating fetal well-being) or non-reactive (suggesting potential fetal compromise).

Choice D rationale

A positive non-stress test is also not a standard term used for NST interpretation. A positive result in fetal monitoring typically refers to a contraction stress test where late decelerations are observed, indicating potential uteroplacental insufficiency.

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A nurse is caring for a 32-year-old female client who is 2 days postpartum in the postpartum unit. Exhibits For each potential client finding, click to specify if the finding is expected or unexpected.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is 1 hour postpartum and observes a large amount of lochia rubra and several small clots 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 A

Explanation

When performing a Non-Stress test, the nurse interprets the finding of two accelerations of the fetal heart rate of 15 beats per minute above the baseline rate of 135 beats per minute lasting for 15 seconds in 20 minutes.This should be documented as:

Correct Answer is A

Explanation

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Which of the following are common methods used for the induction of labor in obstetric practice? (Select All that Apply)

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The nurse is managing care of a primigravida at full term who is in the active phase of labor.What should be included in developing the plan of care for this client?

The nurse is assessing the lochia on a 1-day postpartum patient.The nurse notes that the lochia is red and has a foul-smelling odor.The nurse determines that this assessment finding:

A nurse is caring for a 32-year-old female client who is 2 days postpartum in the postpartum unit.

Exhibits

For each potential client finding, click to specify if the finding is expected or unexpected.