A nurse is monitoring a client who is 3 days postpartum and is breastfeeding. The nurse notes that the fundus is three fingerbreadths below the umbilicus, lochia rubra is moderate, and the breasts are full and warm to palpation. Which of the following interpretations of these findings should the nurse make?

Additional interventions not indicated at this time.

Application of a heating pad to the breasts is indicated.

The client should be advised to remove her nursing bra.

The client is exhibiting early indications of mastitis.

Answer and Explanation

The Correct Answer is A

Choice A Reason:

The findings described are typical for a client who is 3 days postpartum. The fundus being three fingerbreadths below the umbilicus, moderate lochia rubra, and full, warm breasts are all normal postpartum changes. The fundus should gradually descend into the pelvis, and lochia rubra is expected during the first few days postpartum. Breast fullness and warmth indicate the onset of milk production, which is normal and does not require additional interventions.

Choice B Reason:

Applying a heating pad to the breasts is not indicated in this scenario. While heat can sometimes be used to relieve engorgement, it is not necessary unless the client is experiencing significant discomfort or other symptoms that suggest a need for intervention. The described findings do not indicate such a need.

Choice C Reason:

Advising the client to remove her nursing bra is not appropriate. Wearing a well-fitting nursing bra can provide support and comfort, especially as the breasts become fuller with milk production. There is no indication from the findings that the client should remove her nursing bra

Choice D Reason:

The client is not exhibiting early indications of mastitis. Mastitis typically presents with symptoms such as localized breast pain, redness, fever, and flu-like symptoms. The described findings of full and warm breasts are normal for the postpartum period and do not suggest an infection.

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Correct Answer is A

Explanation

Choice A reason:

Observing for meconium in respiratory secretions is crucial for newborns who are small for gestational age (SGA). Meconium aspiration syndrome (MAS) is a significant risk for these infants. Meconium, the first stool of an infant, can be passed into the amniotic fluid before or during labor, especially in cases of fetal distress. If the newborn inhales this meconium-stained fluid, it can lead to severe respiratory issues, including airway obstruction, inflammation, and infection. Therefore, careful monitoring and immediate intervention are necessary to prevent complications associated with MAS.

Choice B reason:

Monitoring for hyperthermia is not typically a primary concern for SGA infants. These infants are more prone to hypothermia due to their lower body fat and reduced ability to regulate body temperature. While maintaining a stable temperature is essential, the risk of hyperthermia is less common compared to hypothermia. Therefore, this intervention is not as critical as others for SGA infants.

Choice C reason:

Identifying manifestations of anemia is important but not the most immediate concern for SGA infants. Anemia can occur in these infants due to various factors, including intrauterine growth restriction and maternal conditions. However, the immediate postnatal period requires more urgent interventions, such as monitoring for respiratory distress and hypoglycemia. Anemia can be assessed and managed as part of the ongoing care plan.

Choice D reason:

Monitoring for hyperglycemia is not a primary concern for SGA infants. In fact, these infants are at a higher risk of hypoglycemia due to their limited glycogen stores and increased metabolic demands. Hypoglycemia can lead to serious complications, including neurological damage if not promptly addressed. Therefore, monitoring blood glucose levels and ensuring adequate nutrition are critical interventions for SGA infants.

A. Reddened with a small amount of bloody drainage. B. Pink without drainage. C. Reddened with a scant amount of yellow exudate. D. Reddened, with copious blood.

Correct Answer is C

Explanation

Choice A Reason:

Reddened with a small amount of bloody drainage is a common finding immediately after circumcision. However, this is not the expected appearance after the initial healing phase. The presence of bloody drainage should decrease over time, and the site should begin to show signs of healing.

Choice B Reason:

Pink without drainage is not typical immediately after circumcision. The surgical site will usually be red and may have some drainage as part of the normal healing process. A completely pink and dry site would be expected only after full healing has occurred.

Choice C Reason:

Reddened with a scant amount of yellow exudate is the expected appearance during the healing process. The yellow exudate is part of the normal healing response and should not be mistaken for infection. This exudate typically appears within the first few days after circumcision and indicates that the healing process is progressing normally.

Choice D Reason:

Reddened, with copious blood is not normal and indicates a potential complication. Copious bleeding from the circumcision site requires immediate medical attention as it may suggest an issue with clotting or a problem with the surgical site.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is at 40 weeks of gestation and is in labor. The client’s ultrasound examination indicates that the fetus is small for gestational age (SG

Correct Answer is A

Explanation

A male newborn infant has just been circumcised. The nurse checks the surgical site, expecting it to have what appearance?

Correct Answer is C

Explanation

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A nurse in a provider’s office is caring for a client who is at 34 weeks of gestation and at risk for placental abruption. The nurse should recognize that which of the following is the most common risk factor for abruption?