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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Related Questions
Correct Answer is A
Explanation
This action helps to prevent cold stress. This is because cold stress is a condition where the newborn's core temperature drops below 36.5°C and they use energy and oxygen to generate warmth. This can lead to hypoglycemia, metabolic acidosis, hypoxia, and an increased risk of infection.
Placing the newborn under a radiant warmer provides thermal stability and prevents heat loss by radiation.
Choice B is wrong because thermogenesis is the process of heat production, not a complication.
Choice C is wrong because shivering is a mechanism of heat production in adults, not in newborns.
Choice D is wrong because brown fat production is a normal feature of newborns that helps them generate heat by lipolysis.
Here is an image of a newborn under a radiant warmer.
Correct Answer is C
Explanation
Place the infant on the mother's abdomen after birth. This will help the infant maintain an adequate body temperature by providing skin-to-skin contact with the mother, which reduces heat loss and promotes bonding. Skin-to-skin contact also stimulates the baby's natural feeding cues and helps initiate breastfeeding.
Choice A is not correct because turning up the temperature in the birth room may not be enough to prevent heat loss from the infant, especially if they are wet or exposed to cold surfaces. It may also make the mother uncomfortable or dehydrated.
Choice B is not correct because bathing the infant immediately after birth may increase heat loss from evaporation and conduction. It may also interfere with the baby's natural protective coating (vernix) and microbiome. Bathing should be delayed until at least 24 hours after birth.
Choice D is not correct because wrapping the infant in a warm, dry blanket may not provide the same benefits as skin-to-skin contact with the mother. It may also prevent the baby from smelling and seeing the mother's breast, which are important cues for breastfeeding initiation.
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