When the nurse is assessing a postpartum client approximately 6 hours after delivery, which finding would warrant further investigation?
Select one:

Moderate amounts of deep red lochia.

Sweating while afebrile.

Voiding 350 mL of blood-tinged urine.

Heart rate of 115 beats/minute.

Answer and Explanation

The Correct Answer is D

Choice A Reason: Moderate amounts of deep red lochia. This is not a finding that would warrant further investigation, but rather a normal finding for the early postpartum period. Lochia is the vaginal discharge that occurs after delivery, which consists of blood, mucus, and tissue from the uterus. Lochia is usually deep red in color and moderate in amount for the first few days after delivery.

Choice B Reason: Sweating while afebrile. This is not a finding that would warrant further investigation, but rather a common occurrence in the postpartum period. Sweating is a mechanism of thermoregulation that helps the body eliminate excess ﬂuid and electrolytes that were retained during pregnancy. Sweating does not necessarily indicate fever or infection.

Choice C Reason: Voiding 350 mL of blood-tinged urine. This is not a finding that would warrant further investigation, but rather an expected outcome for the postpartum period. Voiding large amounts of urine is normal in the postpartum period, as the body eliminates the excess ﬂuid that was accumulated during pregnancy. Blood-tinged urine may be due to trauma or irritation of the urinary tract during labor or delivery, which usually resolves within a few days.

Choice D Reason: Heart rate of 115 beats/minute. This is because a heart rate of 115 beats/minute is higher than the normal range for an adult, which is 60 to 100 beats/minute. A high heart rate may indicate postpartum hemorrhage, infection, pain, anxiety, or dehydration. The nurse should further assess the client for other signs and symptoms of these conditions and notify the physician if necessary.

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Correct Answer is D

Explanation

Choice A Reason: Taking the newborn to the nursery for the initial assessment. This is an ineﬀective intervention that disrupts parental atachment by separating the mother and the newborn. It also deprives the newborn of the benefits of skin to skin contact and breastfeeding.

Choice B Reason: Allowing the mother a chance to rest without the baby immediately after delivery. This is an unnecessary intervention that delays parental atachment by postponing the first contact between the mother and the newborn. It also ignores the mother's desire and readiness to hold and feed her baby.

Choice C Reason: Placing the newborn under a radiant warmer to do the initial assessment. This is an outdated intervention that hinders parental atachment by creating a physical barrier between the mother and the newborn. It also exposes the newborn to potential risks such as dehydration, hyperthermia, or eye damage.

Choice D Reason: Placing the newborn on the maternal abdomen and doing the initial assessment. This is because this intervention facilitates skin to skin contact, eye contact, and bonding between the mother and the newborn. It also enhances breastfeeding initiation, thermoregulation, and maternal-infant atachment.

A. "Our baby's newborn rash is from this syndrome." B. "His face looks like it does due to this problem." C. "He can show signs of withdrawal from alcohol exposure like jiteriness, sweating, hyper reﬂexes, poor feeding and not sleeping well." D. "He is at risk of having intellectual disabilities, so we will need to get extra services to support him."

Correct Answer is A

Explanation

Choice A Reason: "Our baby's newborn rash is from this syndrome." This is because this statement by a parent indicates that additional teaching is required, as it shows a misunderstanding or confusion about FAS and its manifestations. FAS is a condition that occurs when a woman consumes alcohol during pregnancy, which can aﬀect the development and function of various organs and systems in the fetus and child. FAS can cause physical, behavioral, and cognitive problems such as facial abnormalities, growth retardation, learning difficulties, and atention deficits. FAS does not cause newborn rash, which is a common and benign condition that aﬀects many newborns regardless of maternal alcohol intake. Newborn rash is also known as erythema toxicum neonatorum or baby acne, which is characterized by small red bumps or pustules on the face, chest, or back that usually disappear within a few weeks.

Choice B Reason: "His face looks like it does due to this problem." This is a correct answer that indicates adequate understanding of FAS and its features. Facial abnormalities are one of the characteristic signs of FAS, which include small eye openings, thin upper lip, ﬂat nasal bridge, and smooth philtrum (the groove between the nose and upper lip).

Choice C Reason: "He can show signs of withdrawal from alcohol exposure like jiteriness, sweating, hyper reﬂexes, poor feeding and not sleeping well." This is a correct answer that indicates adequate understanding of FAS and its complications. Signs of withdrawal are possible eﬀects of FAS, which occur when the fetus or newborn is exposed to alcohol in utero or through breast milk, which can cause neurotoxicity and dependency. Signs of withdrawal can include jiteriness, sweating, hyper reﬂexes, poor feeding, and not sleeping well, as well as irritability, seizures, or tremors.

Choice D Reason: "He is at risk of having intellectual disabilities, so we will need to get extra services to support him." This is a correct answer that indicates adequate understanding of FAS and its implications. Intellectual disabilities are potential outcomes of FAS, which aﬀect the cognitive development and function of the child. Intellectual disabilities can cause problems with memory, Reasoning, language, and social skills. Extra services and support may be needed to help the child achieve their optimal potential and quality of life.

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When the nurse is assessing a postpartum client approximately 6 hours after delivery, which finding would warrant further investigation? Select one:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

After the birth of a newborn, the nursing intervention that most eﬀectively promotes parental atachment is: Select one:

Correct Answer is D

Explanation

Parents have been told their child has fetal alcohol syndrome (FAS). Which statement by a parent indicates that additional teaching is required? Select one:

Correct Answer is A

Explanation

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When the nurse is assessing a postpartum client approximately 6 hours after delivery, which finding would warrant further investigation?
Select one: