A woman had a vaginal delivery two days ago and is preparing for discharge. To help prevent postpartum complications, the nurse plans to teach the woman to report any:

Change in lochia from red to white

Fatigue and irritability

Fever

Contractions

Answer and Explanation

The Correct Answer is C

Fever. This is because fever is a sign of infection, which is a common and potentially serious postpartum complication. Infection can affect various parts of the body, such as the uterus (endometritis), the bladder (cystitis), the breast (mastitis), the wound (wound infection), or the blood (sepsis). Infection can cause symptoms such as fever, chills, pain, foul-smelling discharge, redness, swelling, or warmth at the site of infection.

Choice A is not correct because the change in lochia from red to white is not a sign of postpartum complication. Lochia is the vaginal discharge that occurs after childbirth. It changes color and amount over time, from red to pink to brown to yellow to white. This is a normal process of healing and does not indicate a problem unless the lochia is foul-smelling, heavy, or contains large clots³.

Choice B is not correct because fatigue and irritability are not signs of postpartum complications. Fatigue and irritability are common feelings after childbirth due to hormonal changes, sleep deprivation, physical recovery, and emotional adjustment. They do not necessarily indicate a problem unless they are severe or persistent and interfere with daily functioning or bonding with the baby.

Choice D is not correct because contractions are not signs of postpartum complication. Contractions are normal after childbirth and help the uterus shrink back to its pre-pregnancy size. They are usually mild and subside within a few days. They may be more intense during breastfeeding due to the release of oxytocin, which stimulates uterine contractions.

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Correct Answer is D

Explanation

Sternal or chest retractions. This is because sternal or chest retractions are a sign of respiratory distress in newborns, which means they are having difficulty breathing. Chest retractions occur when the baby's chest pulls in with each breath, indicating that they are using extra muscles to breathe. This can be caused by various conditions that affect the lungs, such as respiratory distress syndrome (RDS), transient tachypnea of the newborn (TTN), meconium aspiration syndrome (MAS), pneumonia, or congenital heart defects.

Choice A is not correct because mucus draining from the nose is not a symptom of respiratory distress in newborns. It is normal for newborns to have some mucus in their nose and mouth after birth, which can be cleared by suctioning or wiping.

Mucus drainage does not interfere with breathing unless it is excessive or thick.

Choice B is not correct because cyanosis of the hands and feet is not a symptom of respiratory distress in newborns. It is normal for newborns to have bluish discoloration of their hands and feet, called acrocyanosis, for the first few days after birth. This is due to immature circulation and does not indicate a lack of oxygen. Cyanosis of the central parts of the body, such as the face, lips, and tongue, is more concerning and should be reported.

Choice C is not correct because irregular heart rate is not a symptom of respiratory distress in newborns. It is normal for newborns to have some variations in their heart rate, especially during sleep cycles. The normal heart rate range for newborns is 100 to 160 beats per minute. A heart rate that is too fast (tachycardia) or too slow (bradycardia) may indicate a problem with the heart or other organs³.

A. Document expected postpartum mucous membrane congestion B. Notify the charge nurse of a possible upper respiratory infection C. Notify the physician of a possible pulmonary embolism D. Medicate with antipyretic remedy for elevated temperature

Correct Answer is C

Explanation

Notify the physician of a possible pulmonary embolism. This is because the client's symptoms suggest that she has a pulmonary embolism, which is a blockage of a blood vessel in the lungs often caused by blood clots that travel from the legs. Pulmonary embolism is a life-threateningcondition that requires immediate medical attention. The client may also have chest pain, coughing up blood, dizziness, or fainting.

Choice A is wrong because postpartum mucous membrane congestion does not cause fever, cough, or shortness of breath.

Choice B is wrong because an upper respiratory infection does not cause edema and redness along the saphenous vein.

Choice D is wrong because an antipyretic remedy does not treat the underlying cause of the fever and may mask the severity of the condition.

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A woman had a vaginal delivery two days ago and is preparing for discharge. To help prevent postpartum complications, the nurse plans to teach the woman to report any:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Shortly after delivery, a symptom of respiratory distress in the newborn that should be reported is:

Correct Answer is D

Explanation

The 1-day postpartum patient shows a temperature elevation, cough, and slight shortness of breath on exertion. Based on these symptoms, the nurse should:

Correct Answer is C

Explanation

Within three days of birth, a newborn has developed a yellowish tinge that extends from the face to mid-chest is lethargic, and has to be awakened to feed. Which condition does the nurse suspect this infant is manifesting?

Which finding would alert the nurse to suspect that a newborn is experiencing respiratory distress?

The nurse is preparing to administer the vitamin K injection to a newborn. Which action would be correct for this client?

Five days after a spontaneous vaginal delivery, a woman comes to the emergency room because she has a fever and persistent cramping. The nurse recognizes that the cause of these signs and symptoms may be:

When the newborn's crib was moved suddenly, the nurse noticed that his legs flexed and the arms fanned out, and then both came back toward the midline. The nurse would interpret this behavior as:

A woman had a vaginal delivery two days ago and is preparing for discharge. To help prevent postpartum complications, the nurse plans to teach the woman to report any:

The nurse is caring for a new mother and newborn in a rooming-in unit and watches the mother put the infant in the bed, lying on her side, propped up with a pillow. The nurse should point out that this position can increase the risk of which situation?