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 A
Explanation
A) Correct - Dysuria (painful urination) could indicate a urinary tract infection (UTI) which, if left untreated, can lead to complications during pregnancy. It requires prompt evaluation and treatment.
B) Incorrect- Varicose veins and gingivitis are common discomforts during pregnancy, but they are not typically considered urgent issues.
C) Incorrect- Gingivitis (inflammation of the gums) is common during pregnancy and should be addressed, but it is not as urgent as a potential UTI.
D) Incorrect- Leukorrhea (white vaginal discharge) is a common occurrence during pregnancy and is usually not a priority concern unless it's accompanied by other symptoms.
Correct Answer is B
Explanation
A) Incorrect- Foul-smelling vaginal discharge might indicate infection but is not the priority over the presence of meconium-stained amniotic fluid.
B) Correct- Fetal heart rate is important to monitor, but the presence of meconium- stained amniotic fluid has higher priority. fetal heart tones 98/min, because this indicates fetal distress and requires immediate intervention.
C) Incorrect - Amniotic fluid with meconium noted could indicate fetal hypoxia or distress, but it is not always a sign of a problem and depends on other factors such as gestational age and fetal activity.
D) Incorrect- Maternal temperature elevation might indicate infection but is not the priority over assessing the condition of the amniotic fluid and the baby.
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