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 {"dropdown-group-1":"B"}
Explanation
The Apgar score is a scoring system used by doctors and nurses to assess newborns one minute and five minutes after they are born. The score is based on five criteria: activity, pulse, grimace, appearance, and respiration, with each criterion receiving a score of 0 to 2 points.
If we apply this scoring system to the information provided, the newborn's 1- minute Apgar score would be:
Activity: 1 point (limbs flexed)
Pulse: 1 point (heart rate less than 100 beats per minute) Grimace: 1 point (facial movement/grimace with stimulation) Appearance: 1 point (body pink but extremities blue) Respiration: 1 point (irregular, weak crying)
The total score is 5 points, which is considered moderately abnormal.
Correct Answer is B
Explanation
Pathologic jaundice. This type of jaundice occurs within the first 24 hours of birth and is caused by an underlying health condition, such as blood type incompatibility, infection, or liver problems. It can lead to serious complications, such as brain damage, if not treated promptly. Pathologic jaundice requires medical attention and often involves phototherapy or blood transfusion to lower the bilirubin levels in the baby's blood.
Choice A is not correct because physiologic jaundice is a normal and harmless condition that affects most newborns. It usually appears between the second and fourth day after birth and resolves by the second week. It is caused by the immature liver's inability to process bilirubin efficiently.
Choice C is not correct because breast milk jaundice is a rare condition that affects some breastfed babies. It usually appears after the first week of life and lasts up to a month or longer. It is caused by a substance in breast milk that interferes with the liver's ability to eliminate bilirubin.
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