A nurse is collecting data from a postpartum client and finds a large amount of lochia rubra with several clots on the client's perineal pad. Which of the following actions should the nurse take first?

Request the provider perform a vaginal examination.

Check the client's fundus.

Measure the client's vital signs.

Feel for a full bladder.

Answer and Explanation

The Correct Answer is B

Check the client's fundus. Lochia rubra is the normal vaginal bleeding and discharge that occurs after childbirth. It consists of blood, mucus, and tissue from the placenta and the uterus lining. It is usually bright red and may have some clots, but these clots should not be big or difficult to pass. If the client has a large amount of lochia rubra with several clots, it may indicate that the uterus is not contracting well and needs to be massaged to expel any retained tissue or blood. Checking the client's fundus is the first action the nurse should take to assess the uterine tone and location.

Choice A is incorrect because requesting the provider perform a vaginal examination is not the first action the nurse should take. A vaginal examination may be necessary if the fundal massage does not reduce the bleeding or if there is a suspicion of lacerations or hematoma, but it is not a priority intervention.

Choice C is incorrect because measuring the client's vital signs is not the first action the nurse should take. Vital signs can help monitor the client's hemodynamic status and identify signs of shock, such as tachycardia, hypotension, and pallor, but they are not as important as checking the fundus in this situation.

Choice D is incorrect because feeling for a full bladder is not the first action the nurse should take. A full bladder can displace the uterus and interfere with its contraction, leading to increased bleeding. However, it is not as likely as uterine atony to cause a large amount of lochia rubra with several clots.

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Correct Answer is C

Explanation

Leave the milia alone: it will disappear spontaneously. No treatment is needed. Milia are small, white cysts that form on the skin, usually on the face, nose, or cheeks of newborns. They are harmless and very common, affecting about half of all healthy infants. They are caused by dead skin cells trapped in pockets of the skin or mouth. They are not a type of acne and are not related to breastfeeding or formula feeding. They usually go away on their own within a few weeks or months without any intervention.

Choice A is incorrect because squeezing out the white material can damage the skin and cause infection or scarring.

Choice B is incorrect because contacting a pediatric dermatologist is unnecessary and expensive for a benign condition that resolves by itself.

Choice D is incorrect because washing the baby's face with a mild astringent can irritate the skin and make the milia worse.

A. Clear the respiratory tract. B. Dry the infant off and cover the head. C. Stimulate the infant to cry. D. Clamp the umbilical cord.

Correct Answer is A

Explanation

Clear the respiratory tract. This is because clearing the respiratory tract is the first step in the initial care of a newborn following vaginal delivery. The respiratory tract includes the nose, mouth, and lungs.

Clearing the respiratory tract helps the baby breathe more easily and prevents aspiration of amniotic fluid, blood, or mucus. The nurse can use a bulb syringe or a suction device to gently remove any fluid from the baby's nose and mouth.

Choice B is not correct because drying the infant off and covering the head is not the first action to take. Drying and covering the infant helps prevent heat loss and hypothermia, which are important for newborn care. However, this should be done after clearing the respiratory tract.

Choice C is not correct because stimulating the infant to cry is not the first action to take. Stimulating the infant to cry can help expand the lungs and improve oxygenation, which is also important for newborn care. However, this should be done after clearing the respiratory tract.

Choice D is not correct because clamping the umbilical cord is not the first action to take. Clamping and cutting the umbilical cord separates the baby from the placenta, which is no longer needed after birth. However, this should be done after clearing the respiratory tract.

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A nurse is collecting data from a postpartum client and finds a large amount of lochia rubra with several clots on the client's perineal pad. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Parents express concern about the milia on the face and nose of their baby. The nurse's most helpful response would be to instruct the parents to:

Correct Answer is C

Explanation

A nurse is assisting with the care of a newborn following a vaginal delivery. Which of the following actions should the nurse perform first?

Correct Answer is A

Explanation

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