A nurse is collecting data from a client who delivered 2 hours ago. The client has moderate lochia rubra, temperature within normal limits, breasts soft, fundus firm, slightly deviated to the right, pulse rate 88/min, respiratory rate 18/min.
Which of the following actions should the nurse perform?
Encourage the client to nurse more frequently so her milk will come in
Report the client's temperature elevation
Ask the client to empty her bladder
Increase IV fluids
The Correct Answer is C
ask the client to empty her bladder. A full bladder can cause the uterus to be displaced and lead to excessive bleeding. The moderate lochia rubra, normal temperature, soft breasts, firm fundus, slightly deviated to the right, pulse rate of 88/min, and respiratory rate of 18/min are all normal findings.
Choice A is not correct because the client's milk will come in regardless of nursing frequency.
Choice B is not correct because the client's temperature is within normal limits.
Choice D is not correct because there is no indication of an increase in IV fluids.
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Correct Answer is C
Explanation
Administer low concentrations of oxygen. Retinopathy of prematurity (ROP) is a disease of retinal vascular and capillary proliferation affecting premature infants undergoing oxygen therapy. Oxygen treatment results in pathologic growth of vessels in the developing retina that may lead to permanent damage to the retina as well as retinal detachment and macular folds. Administering low concentrations of oxygen can help prevent ROP by reducing the oxygen-induced vasoconstriction and vascular endothelial growth factor (VEGF) expression.
Choice A is not correct because keeping the infant's eyes covered at all times does not prevent ROP. In fact, it may increase the risk of infection or injury to the eyes.
Choice B is not correct because positioning with the head slightly lower than the body does not prevent ROP. It may increase the intracranial pressure and affect the cerebral blood flow.
Choice D is not correct because monitoring arterial oxygen levels with a pulse oximeter does not prevent ROP. It is a useful tool to guide oxygen therapy, but it does not directly affect retinal vascular development.
Correct Answer is A
Explanation
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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