The nurse is assessing the lochia on a 1-day postpartum patient.
The nurse notes that the lochia is red and has a foul-smelling odor.
The nurse determines that this assessment finding:

Indicates the need for increasing ambulation.

Indicates the need for increasing oral fluids.

Indicates the presence of infection.

Is normal.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Increasing ambulation is generally encouraged in the postpartum period to prevent complications like thrombophlebitis, but it does not address the potential cause of foul-smelling lochia. Foul odor is a key indicator of infection, and ambulation will not resolve an existing infection.

Choice B rationale

Increasing oral fluids is important for hydration in the postpartum period, but it will not directly address a foul-smelling odor in the lochia. While adequate hydration supports overall healing, it does not treat an infection. A foul odor strongly suggests a localized infectious process in the uterus.

Choice C rationale

Lochia that is red (rubra) is normal in the first few days postpartum. However, a foul-smelling odor is an abnormal finding and a significant indicator of a potential uterine infection, also known as endometritis or puerperal infection. Further assessment and intervention are required to identify and treat the infection.

Choice D rationale

Normal lochia progresses from rubra (red) to serosa (pinkish-brown) to alba (yellowish-white) over several weeks postpartum. Normal lochia should have a fleshy, not foul, odor. A foul smell is an abnormal finding that suggests an infectious process within the uterus and requires prompt attention.

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Correct Answer is A

Explanation

Choice A rationale

A reactive nonstress test demonstrates at least two accelerations in fetal heart rate, defined as an increase of 15 beats per minute above the baseline lasting for 15 seconds, within a 20-minute period. These accelerations indicate adequate fetal oxygenation and a healthy fetal autonomic nervous system response to movement.

Choice B rationale

Drawing blood to evaluate the baby's risk of genetic problems is typically performed through procedures like amniocentesis or chorionic villus sampling, not during a nonstress test. A nonstress test assesses fetal well-being based on heart rate patterns in response to fetal movement.

Choice C rationale

While fetal movement is an indicator of fetal well-being, the nonstress test specifically evaluates the fetal heart rate response to that movement. The number of movements within a specific time frame is a component of a biophysical profile, not the sole indicator in a nonstress test.

Choice D rationale

Ultrasound is used to visualize fetal anatomy and assess for congenital anomalies, which is a component of a fetal anatomy scan typically performed around 18-20 weeks of gestation. A nonstress test primarily monitors fetal heart rate and its reactivity.

A. Express small amounts of milk from the breasts to relieve the pressure. B. Wearing a loose-fitting bra to prevent nipple irritation. C. Apply cold packs to the breasts for comfort. D. Run warm water on her breasts during a shower.

Correct Answer is C

Explanation

Choice A rationale

Expressing milk when bottle-feeding can stimulate further milk production, which would exacerbate the engorgement and discomfort. The goal is to discourage milk production.

Choice B rationale

While a supportive bra is generally recommended for comfort, a loose-fitting bra might not provide adequate support to reduce swelling and discomfort associated with engorgement. A firm, supportive bra is usually advised.

Choice C rationale

Cold packs cause vasoconstriction, which helps to reduce blood flow to the breasts, thereby decreasing swelling, inflammation, and pain associated with engorgement. This provides symptomatic relief without stimulating milk production.

Choice D rationale

Warm water can stimulate milk flow, which is counterproductive when trying to suppress lactation in a bottle-feeding mother experiencing engorgement. Warmth increases blood flow and can worsen swelling and discomfort.

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The nurse is assessing the lochia on a 1-day postpartum patient.The nurse notes that the lochia is red and has a foul-smelling odor.The nurse determines that this assessment finding:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is performing a nonstress test (NST) on a client who is at 36 weeks of gestation and asks "what are you looking for during this test?" Which of the following responses should the nurse make?

Correct Answer is A

Explanation

A woman gave birth 48 hours ago to a healthy infant girl.She has decided to bottle feed.During the assessment, the nurse notices that both breasts are swollen, warm, and tender on palpation.Which guidance should the nurse provide to the client at this time?

Correct Answer is C

Explanation

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The nurse is assessing the lochia on a 1-day postpartum patient.
The nurse notes that the lochia is red and has a foul-smelling odor.
The nurse determines that this assessment finding: