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 A

Explanation

Choice A Reason: Central cyanosis and poor tone. These are signs of hypoxia and asphyxia in newborns, which indicate a need for resuscitation. Central cyanosis means bluish discoloration of the skin or mucous membranes around the mouth, nose, or eyes. Poor tone means limpness or lack of muscle activity.

Choice B Reason: Heart rate of 160 beats per minute and spitting up mucus. These are not signs of hypoxia or asphyxia in newborns, but rather normal findings or minor issues. A normal heart rate for a newborn ranges from 120 to 160 beats per minute. Spitting up mucus may be due to excess secretions or swallowing amniotic ﬂuid, which can be cleared by suctioning or burping.

Choice C Reason: Crying with respirations of greater than 60 breaths per minute. These are not signs of hypoxia or asphyxia in newborns, but rather normal or expected findings. Crying indicates that the newborn has a patent airway and adequate lung expansion. Respirations of greater than 60 breaths per minute may be normal for a newborn in transition or due to transient tachypnea, which usually resolves within a few hours.

Choice D Reason: Blue hands and feet but lips that are slowly pinking up. These are not signs of hypoxia or asphyxia in newborns, but rather a common condition called acrocyanosis. Acrocyanosis means bluish discoloration of the hands and feet due to poor peripheral circulation in response to cold exposure or stress. It does not aﬀect oxygenation or ventilation and usually disappears within 24 to 48 hours after birth.

A. Continuing to monitor and document fetal heart rate. B. Changing the mother's position to left lateral and giving oxygen by nasal cannula. C. With a sterile glove, maintaining pressure to lift the presenting part and emergently notifying the provider for a STAT C-section. D. Bolusing the patient with 1000cc lactated ringers

Correct Answer is C

Explanation

Choice A Reason: Continuing to monitor and document fetal heart rate. This is an inadequate response that does not address the urgency of the situation or intervene to prevent fetal distress or demise.

Choice B Reason: Changing the mother's position to left lateral and giving oxygen by nasal cannula. This is a partial response that may improve maternal-fetal blood ﬂow and oxygenation, but it does not resolve the cord compression or facilitate delivery.

Choice C Reason: With a sterile glove, maintaining pressure to lift the presenting part and emergently notifying the provider for a STAT C-section. This is an appropriate response that aims to reduce the cord compression by elevating the fetal head away from the cord and prepare for an immediate cesarean delivery.

Choice D Reason: Bolusing the patient with 1000cc lactated ringers. This is an irrelevant response that does not address the cause of the problem or improve fetal outcome.

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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

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Correct Answer is A

Explanation

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Select one: