A nurse is collecting data from a client who is 20 hr postpartum following a vaginal delivery. Which of the following findings should the nurse expect?

Positive Homans' sign

Full, firm breasts

Firm fundus at midline

Lochia serosa

Answer and Explanation

The Correct Answer is C

A.   Homans' sign is a test for deep vein thrombosis and is not a normal postpartum finding.
B.   Full, firm breasts typically occur a few days after delivery when milk production begins, not at 20 hours postpartum.
C.   A firm fundus at the midline is an expected finding in the immediate postpartum period, indicating that the uterus is contracting and involuting properly.
D.   Lochia serosa (pinkish-brown discharge) is a normal finding around 3 to 10 days postpartum, but it is not typically present at 20 hours postpartum.

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Correct Answer is D

Explanation

A. Elevating a baby's head on a cushion during sleep is not recommended, as it may increase the risk of Sudden Infant Death Syndrome (SIDS).
B. Using baby powder with each diaper change is not recommended, as it can be harmful if inhaled by the baby.
C. Setting the hot water heater to 130 degrees Fahrenheit is too hot and can scald a baby. The recommended temperature is around 120 degrees Fahrenheit.
D. This statement indicates an understanding of the importance of regularly changing smoke detector batteries, which is a critical aspect of newborn safety.

A. “This infection can cause your baby to experience hearing loss at birth." B. “If you test positive for GBS, the provider will need to perform a cesarean birth." C. "You will be tested again for GBS at about 36 weeks of gestation." D. "You will take an antibiotic during the last 2 weeks of pregnancy to avoid transferring GBS to your baby."

Correct Answer is C

Explanation

A: This infection does not directly cause hearing loss at birth. Hearing loss in newborns can be associated with genetic factors, birth complications, and certain infections, but GBS is not known to be a direct cause of hearing impairment.

B: A positive GBS test result does not necessitate a cesarean birth. The standard management for GBS-positive mothers is the administration of intrapartum antibiotic prophylaxis, not cesarean delivery, unless there are other obstetric indications.

C: Testing for GBS is typically done between 36 and 37 weeks of gestation because this timing is close to delivery, when the test results are most predictive of the baby's risk of exposure during birth.

D: Antibiotics are not given during the last 2 weeks of pregnancy to prevent GBS transmission. Instead, they are administered during labor to ensure effective levels of the drug during delivery, which is the critical period for preventing transmission to the baby.

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A nurse is collecting data from a client who is 20 hr postpartum following a vaginal delivery. Which of the following findings should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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