A nurse on a postpartum unit is caring for a client who delivered vaginally 24 hr ago.
Which of the following should the nurse expect to find when collecting data?
Moderate lochia serosa on perineal pads
Frequent urges to urinate
Uterine fundus 2 finger widths above the umbilicus
colostrum expressed from the breast
The Correct Answer is A
A) Correct - Lochia serosa, a pinkish-brown vaginal discharge, is typically present 24 hours after vaginal delivery. It is the second stage of lochia that follows the bright red lochia rubra.
B) Incorrect- Frequent urges to urinate might be present but are not specific to the 24- hour postpartum period.
C) Incorrect- The uterine fundus should be descending in the days after childbirth, not located 2 finger widths above the umbilicus.
D) Incorrect- Colostrum is the early milk produced by the breasts, but its presence is not a specific finding in the immediate postpartum period.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A) Incorrect- Using a breast pump can actually help relieve breast engorgement by expressing excess milk, so this advice is not appropriate.
B) Incorrect- Applying ice packs to the breasts can decrease milk production and might not provide as much relief as other interventions.
C) Incorrect- Wearing a supportive, well-fitting bra is a good recommendation, but it might not provide enough relief for breast engorgement on its own.
D) Correct - Applying purified lanolin to the breasts can help soothe and moisturize the nipples, making breastfeeding more comfortable and providing relief from breast engorgement.
Correct Answer is B
Explanation
A) Incorrect- Urinary retention can be a concern but is not as immediately life-threatening as respiratory depression.
B) Correct - A respiratory rate of 11/min is significantly lower than the normal range and indicates respiratory depression, which can be life-threatening. It requires immediate attention.
C) Incorrect- A blood pressure of 105/62 mm Hg is within a normal range for an adolescent and does not require immediate intervention.
D) Incorrect- Blurred vision might be a side effect of medications, but respiratory depression takes priority due to its potential to lead to serious complications.
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