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 D
Explanation
A. Human placental lactogen (hPL) is a hormone produced by the placenta that helps regulate the metabolism of the mother and fetus, but it is not used as the basis for pregnancy tests. It plays a role in modulating the metabolic state of the mother during pregnancy to facilitate the energy supply of the fetus.
B. Estrogen (estriol) is another hormone produced by the placenta, which is important for maintaining pregnancy and preparing the body for childbirth. However, it is not the hormone detected by pregnancy tests. Estriol levels increase significantly during pregnancy but are not used as a marker for pregnancy tests.
C. Progesterone (progestin) is crucial for maintaining the uterine lining and supporting early pregnancy. While it is essential for a successful pregnancy, it is not the hormone that pregnancy tests detect. Progesterone helps prevent uterine contractions and supports the endometrium.
D. Human chorionic gonadotropin (hCG) is the hormone detected by pregnancy tests. It is produced by the placenta shortly after the embryo attaches to the uterine lining. The presence of hCG in the blood or urine is a reliable indicator of pregnancy, which is why it is the basis for pregnancy tests.
Correct Answer is C
Explanation
Choice A reason:
While hypoglycemia (glucose <45 mg/dL) is concerning,58 mg/dLis within acceptable ranges for many institutions, especially in asymptomatic newborns. Monitoring is required, but it is less urgent than respiratory distress.
Choice B reason:
Respiratory rate of 78 breaths per minute is also within the normal range for a newborn, which typically ranges from 30 to 60 breaths per minute. Though respiratory rate is essential to assess, it does not take priority over other critical issues.
Choice C reason:
Newborns typically have a normal respiratory rate of30-60 breaths/minute. A rate of78indicatessignificant tachypnea, which could signal respiratory distress (e.g., transient tachypnea of the newborn, infection, or respiratory distress syndrome). Rapid breathing can lead to fatigue, hypoxia, or respiratory failure if not promptly addressed.
Choice D reason:
A glucose reading of 58 mg/dL is concerning in a newborn. Hypoglycemia (low blood glucose) can lead to serious complications if not promptly addressed. Newborns are particularly susceptible to hypoglycemia, and it requires immediate assessment and intervention.
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