The nurse assesses the initial lochia post-delivery which is known as:
Rubra.
Fontanalis.
Serosa.
Alba.
The Correct Answer is A
The initial lochia post-delivery is known as lochia rubra.
Lochia is the vaginal discharge that occurs after childbirth and consists of blood, mucus, uterine tissue, and other materials from the uterus.
There are three stages of lochia: lochia rubra, lochia serosa, and lochia alba.
Lochia rubra is dark or bright red in color and lasts for about three to four days after delivery.
Choice B is not an answer because Fontanalis is not a term related to lochia.
Choice C is not an answer because lochia serosa is the second stage of lochia and occurs after lochia rubra.
Choice D is not an answer because lochia alba is the last stage of lochia and occurs after lochia serosa.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
This is a diagnostic procedure that involves inserting a needle into the uterus to obtain a sample of amniotic fluid for testing.
This procedure can cause a small amount of fetal blood to enter the maternal circulation, which can trigger an immune response in Rh-negative women carrying Rh-positive fetuses.
RhoGAM is a medication that contains antibodies against the Rh factor and prevents the mother from developing her own antibodies that could harm the fetus or future pregnancies.
RhoGAM should be given within 72 hours after amniocentesis to Rh-negative women who are not already sensitized2.
Choice B.
Biophysical Profile is incorrect, as this is a noninvasive diagnostic procedure that involves ultrasound and fetal heart rate monitoring to assess fetal well-being.
This procedure does not cause fetomaternal hemorrhage and does not require RhoGAM administration.
Choice C.
The contraction stress test is incorrect, as this is a noninvasive diagnostic procedure that involves inducing uterine contractions and monitoring fetal heart rate response to assess fetal oxygenation.
This procedure does not cause fetomaternal hemorrhage and does not require RhoGAM administration.
Choice D.
A nonstress test is incorrect, as this is a noninvasive diagnostic procedure that involves monitoring fetal heart rate and movement to assess fetal well-being.
This procedure does not cause fetomaternal hemorrhage and does not require RhoGAM administration.
Therefore, choice A is the best answer to this question.
Correct Answer is C
Explanation
Choice A reason:
Placing traction weights so they touch the head of the bed disrupts the effectiveness of the traction system. Skeletal traction relies on a continuous pulling force to maintain proper alignment of the fractured femur. If the weights are resting on any surface, the force is interrupted, which can lead to complications such as malunion or delayed healing. The weights must hang freely at all times to ensure therapeutic benefit.
Choice B reason:
Isometric exercises are beneficial for maintaining muscle tone and promoting circulation during immobilization. However, while this is a supportive intervention, it is not the most critical or immediate nursing action in the context of skeletal traction. Encouraging exercises every 8 hours is appropriate, but it does not directly address the most urgent or discomfort-related aspect of care.
Choice C reason:
Pin care is a routine but potentially painful procedure associated with skeletal traction. Administering pain medication beforehand is a priority nursing action because it ensures client comfort, reduces anxiety, and promotes cooperation during the procedure. This intervention reflects both compassionate care and adherence to best practices in pain management and infection prevention.
Choice D reason:
Repositioning a client in skeletal traction must be done with extreme caution to avoid disrupting the traction setup. Assisting the client to shift position every 4 hours may inadvertently alter the alignment or tension of the traction apparatus. While pressure injury prevention is important, repositioning must be coordinated carefully and is not the most appropriate standalone action in this context.
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