A nurse on a postpartum caring for a client.
For each potential client finding, click to specify if the finding is expected or unexpected.
White blood cell count
Blood clot size
Uterine findings
Lochia findings
Calf findings
Blood pressure
The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"B"}}
Client Finding Assessment:
White blood cell count (18,000/mm³)
Expected: An elevated white blood cell count is common postpartum due to the body's inflammatory response to delivery, especially within the first few days after birth. This level is within the typical postpartum range of 5,000 to 30,000/mm³.
Blood clot size (pea-sized)
Expected: Small blood clots are common during the early postpartum period. It is normal to see some small clots in the lochia as the uterus contracts and expels blood from the uterine lining.
Uterine findings (firm and midline, 1–2 cm below the umbilicus)
Expected: A firm, midline uterus with a descent of about 1–2 cm below the umbilicus is a normal finding during the early postpartum period. This indicates appropriate uterine involution.
Lochia findings (moderate to light amount, no odor, with clots)
Expected: Lochia rubra (red blood flow) is expected during the first few days postpartum, with moderate bleeding and the presence of small clots. The absence of foul odor suggests no infection, which is a positive sign.
Calf findings (one varicose vein visible on left calf)
Expected: It is common for women to have visible varicose veins during pregnancy due to increased blood volume and pressure on the veins. These may persist postpartum, and unless associated with pain or swelling, they do not typically require intervention.
Blood pressure (145/98 mm Hg)
Unexpected: Elevated blood pressure postpartum is concerning and could indicate postpartum hypertension or preeclampsia. This needs to be addressed and monitored closely as it can be a sign of a serious condition that requires further evaluation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) Milia:
Milia are tiny white or yellowish cysts that appear on a newborn's face, particularly on the nose, chin, or forehead. They are caused by the accumulation of keratin under the skin. Milia usually disappear within a few weeks of life and are not related to the pinkish marks described in the question.
B) Telangiectatic nevi (stork bites):
This finding is consistent with telangiectatic nevi, also known as stork bites. These are flat, irregular, pinkish-red marks often found on the forehead, eyelids, and nape of the neck. They are caused by dilated capillaries in the skin and are common in newborns. The marks blanch when pressed and are usually harmless, disappearing within the first 1-2 years of life. This is the correct answer based on the description provided in the question.
C) Nevus flammeus (port wine stain):
A port wine stain is a dark red to purple, flat birthmark caused by capillary malformations. Unlike stork bites, a port wine stain does not blanch when pressed and is typically present for life. It usually appears on the face, neck, or arms, and the coloration remains the same over time.
D) Nevus vasculosus (strawberry mark):
A strawberry mark is a raised, red, and bumpy birthmark that results from proliferation of capillaries. These marks typically appear in the first few weeks of life and grow in size before eventually shrinking and disappearing by the age of 5-10 years. Strawberry marks are not flat, pinkish, or blanchable, making this option unlikely in the scenario described.
Correct Answer is B
Explanation
A) Category I:
Category I fetal heart rate patterns are considered normal and are characterized by a baseline fetal heart rate of 110–160 beats per minute, moderate variability, and the presence of accelerations. The pattern also lacks concerning decelerations. While this client’s fetal heart rate is within the normal baseline range (150 bpm), the presence of occasional variable decelerations indicates that the fetal heart rate pattern does not meet the criteria for Category I.
B) Category II:
Category II includes all fetal heart rate patterns that are not classified as Category I or III. This category represents indeterminate or concerning patterns, which require ongoing assessment and interventions. In this case, the fetal heart rate pattern includes a baseline within the normal range, moderate variability, accelerations, but also occasional variable decelerations. Variable decelerations, particularly when they occur intermittently, are often considered non-reassuring but not immediately concerning if they resolve quickly, placing the pattern in Category II.
C) Uncategorized:
"Uncategorized" refers to situations where the fetal heart rate pattern cannot be classified due to insufficient information or an unclear pattern. This is not applicable here because the nurse has identified sufficient data to classify the pattern.
D) Category III:
Category III patterns are considered abnormal and require prompt intervention. These patterns are characterized by persistent decelerations, such as late decelerations, bradycardia, or variable decelerations that do not resolve with interventions. Since the variable decelerations in this case are occasional and not persistent or severe, this pattern does not meet the criteria for Category III.
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