Choose the sign or symptom that a new mother should be taught to report:
Occasional uterine cramping when the infant nurses.
Descent of the fundus one fingerbreadth each day.
Reappearance of red lochia after it changes to serous.
Oral temperature that is 37.2 C (99 F) in the morning.
The Correct Answer is C
Choice A reason:
Occasional uterine cramping when the infant nurses is a normal phenomenon that occurs as the uterus contracts and returns to its pre-pregnancy size. This is not a sign of infection or complication and does not need to be reported.
Choice B reason:
Descent of the fundus one fingerbreadth each day is also a normal finding that indicates the uterus is involuting properly. The fundus is the top of the uterus that can be felt through the abdomen. It should be at the level of the umbilicus immediately after delivery and then descend about one fingerbreadth (or 1 cm) each day until it reaches the pelvic brim by 10 days postpartum.
Choice C reason:
Reappearance of red lochia after it changes to serous is an abnormal sign that may indicate uterine atony, subinvolution, or retained placental fragments. Lochia is the vaginal discharge that occurs after childbirth, consisting of blood, mucus, and tissue. It usually changes from red to pink to brown to yellow-white over a period of several weeks. If it becomes red again, it may mean that there is bleeding from the uterus or infection in the endometrium. This should be reported to a health care provider as soon as possible.
Choice D reason:
Oral temperature that is 37.2 C (99 F) in the morning is within the normal range and does not indicate fever or infection. A slight elevation in temperature may occur due to dehydration, breast engorgement, or hormonal changes. This does not need to be reported unless it exceeds 38 C (100.4 F) or persists for more than 24 hours.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A: Change her position to the right side
Changing the mother’s position to the right side can sometimes help improve fetal oxygenation by relieving pressure on the vena cava. However, since the mother is already lying on her left side, which is typically the preferred position to optimize blood flow, changing to the right side may not be as effective .
Choice B: Place a wedge under the left hip
Placing a wedge under the left hip is a common intervention to improve uteroplacental blood flow. This position helps to tilt the uterus off the vena cava, enhancing venous return and improving cardiac output, which can positively affect fetal oxygenation. This is why it is the correct answer.
Choice C: Lower the head of the bed
Lowering the head of the bed can help increase blood flow to the upper body and brain, but it does not specifically address the issue of improving uteroplacental blood flow. This action is less targeted for resolving nonreassuring fetal heart rate patterns.
Choice D: Place the mother in a Trendelenburg position
The Trendelenburg position, where the mother is laid flat on her back with her feet elevated higher than her head, is generally used to treat hypotension or to improve venous return in cases of shock. However, it is not typically recommended for nonreassuring fetal heart rate patterns as it can increase pressure on the diaphragm and reduce respiratory efficiency.
Correct Answer is A
Explanation
Choice A reason:
Obtaining blood glucose by heel stick is the appropriate action for a newborn who exhibits signs of diaphoresis, jitteriness, and lethargy. These signs are suggestive of hypoglycemia, which is a common and potentially serious condition in newborns. Hypoglycemia can result from various causes, such as maternal diabetes, prematurity, intrauterine growth restriction, or perinatal stress. A heel stick is a simple and quick method to obtain blood samples from newborns for glucose testing.
Choice B reason:
Initiating phototherapy is not the appropriate action for a newborn who exhibits signs of diaphoresis, jitteriness, and lethargy. Phototherapy is used to treat hyperbilirubinemia, which is a condition characterized by high levels of bilirubin in the blood. Hyperbilirubinemia can cause jaundice, which is a yellowish discoloration of the skin and eyes. Jaundice does not typically cause diaphoresis, jitteriness, or lethargy in newborns.
Choice C reason:
Monitoring the newborn's blood pressure is not the appropriate action for a newborn who exhibits signs of diaphoresis, jitteriness, and lethargy. Blood pressure measurement is not routinely performed in healthy newborns. Blood pressure may be indicated in newborns who have signs of cardiovascular compromise, such as cyanosis, tachycardia, or poor perfusion. Diaphoresis, jitteriness, and lethargy are not specific signs of cardiovascular compromise in newborns.
Choice D reason:
Placing the newborn in a radiant warmer is not the appropriate action for a newborn who exhibits signs of diaphoresis, jitteriness, and lethargy. A radiant warmer is a device that provides heat to maintain the newborn's body temperature. A radiant warmer may be used for newborns who are at risk of hypothermia, such as those who are premature, have low birth weight, or have cold stress. Diaphoresis, jitteriness, and lethargy are not specific signs of hypothermia in newborns.
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