When planning the care for a client during the first 24 hours postpartum, the nurse expects to monitor the client's pulse and blood pressure frequently based on the understanding that the client is at risk for which condition?

Thromboembolism

Cervical laceration

Hemorrhoids

Hemorrhage

Answer and Explanation

The Correct Answer is D

Hemorrhage. This is because postpartum hemorrhage (PPH) is severe bleeding and loss of blood after childbirth that can lead to death. The most common cause of PPH is the uterus not contracting properly after delivery. The nurse needs to monitor the client’s pulse and blood pressure frequently to detect signs of shock and blood loss.

Choice A is wrong because thromboembolism is a blood clot that blocks a blood vessel, not a complication of bleeding.

Choice B is wrong because cervical laceration is a tear in the cervix that can cause bleeding, but it is not a common cause of PPH.

Choice C is wrong because hemorrhoids are swollen veins in the anus or rectum that can cause bleeding, but they are not a common cause of PPH.

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Correct Answer is A

Explanation

This is because cephalhematoma is a collection of blood under the scalp that does not cross the suture line. It is caused by trauma to the head during delivery, such as from vacuum extraction or forceps. It usually appears within a few hours or days after birth and resolves within weeks or months.

Choice B is not correct because nevus flammeus is a type of birthmark that is also known as port-wine stain. It is a flat, red, or purple patch of skin that can appear anywhere on the body, but often on the face. It is caused by abnormal blood vessels in the skin and does not go away over time³.

Choice C is not correct because the molding is the temporary change in the shape of the head due to pressure during delivery. It does not cause swelling or bruising and usually resolves within a few days.

Choice D is not correct because caput succedaneum is a type of swelling that affects the scalp and crosses the suture line. It is caused by fluid accumulation under the scalp due to pressure during delivery. It usually appears at birth and goes away within a few days.

A. Lochia alba B. Lochia normal C. Lochia serosa D. Lochia rubra

Correct Answer is D

Explanation

This is because lochia rubra is the first stage of lochia, the vaginal discharge after giving birth. It comprises blood, shreds of fetal membranes, decidua, vernix caseosa, lanugo, and membranes. It is red in color because of the large amount of blood it contains. It lasts 1 to 4 days after birth.

Choice A is not correct because lochia alba is the last stage of lochia. It is whitish or yellowish-white in color and contains fewer red blood cells and more leukocytes, epithelial cells, cholesterol, fat, mucus, and microorganisms. It lasts from the second through the third to sixth weeks after delivery.

Choice B is not correct because there is no such thing as lochia normal. Lochia has three stages: lochia rubra, lochia serosa and lochia alba.

Choice C is not correct because lochia serosa is the second stage of lochia. It is brownish or pink in color and contains serous exudate, erythrocytes, leukocytes, cervical mucus, and microorganisms. It lasts for 4 to 12 days after delivery.

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When planning the care for a client during the first 24 hours postpartum, the nurse expects to monitor the client's pulse and blood pressure frequently based on the understanding that the client is at risk for which condition?

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Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a newborn and notes a swollen area on the head that does not cross the suture line. The nurse should interpret this finding as which of the following?

Correct Answer is A

Explanation

The nurse assesses a postpartum woman's perineum and notices that her lochial discharge is moderate in amount and red. The nurse would record this as what type of lochia?

Correct Answer is D

Explanation

Parents express concern about the milia on the face and nose of their baby. The nurse's most helpful response would be to instruct the parents to:

A nurse is caring for several newborn clients. For which of the following findings should the nurse notify the charge nurse?

A nurse is assisting with the care of a newborn following a vaginal delivery. Which of the following actions should the nurse perform first?

A nurse is collecting data from a client who delivered 2 hours ago. The client has moderate lochia rubra, temperature within normal limits, breasts soft, fundus firm, slightly deviated to the right, pulse rate 88/min, respiratory rate 18/min. Which of the following actions should the nurse perform?

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:

A nurse is updating the plan of care for a newborn who is undergoing phototherapy. Which of the following actions should the nurse include in the plan?

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?

The nurse assesses a boggy uterus with the fundus above the umbilicus and deviated to the side. The nurse should next assess: