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A multigravida whose peri-pad is 1/4 saturated with lochia rubra after one hour does not need to be reassessed by the RN, as this is a normal finding for a client two hours post-birth. Lochia rubra is the red-colored vaginal discharge that contains blood and debris from the placental site, and it usually lasts for 3 to 4 days after delivery. A peri-pad that is 1/4 saturated after one hour is within the expected range of blood loss.

A multigravida complaining of strong afterbirth pains when breastfeeding does not need to be reassessed by the RN, as this is a normal finding for a client two hours post-birth. Afterbirth pains are cramps caused by uterine contractions that help shrink the uterus and prevent bleeding. They are more common and intense in multiparous women and during breastfeeding, as oxytocin is released and stimulates the contractions.

A primigravida who passed a small clot when she sat up on the edge of the bed does not need to be reassessed by the RN, as this is a normal finding for a client two hours post-birth. Small clots may form in the uterus or vagina due to pooling of blood during rest or anesthesia, and they are usually expelled when changing position or ambulating. As long as the clot is smaller than a plum and there is no excessive bleeding or pain, it is not a cause for concern.

Choice A is incorrect because pregnancy-induced hypertension is a risk factor for
postpartum hemorrhage.

Choice B is incorrect because meconium-stained fluid is not mentioned as a risk factor for postpartum hemorrhage in my sources.

Choice D is incorrect because oligohydramnios is not mentioned as a risk factor for postpartum hemorrhage in my sources.

Choice A is incorrect because using a fetal scalp electrode during labor and delivery is not mentioned as an action that should be included in the plan of care for a client who is pregnant and has HIV in my sources.

Choice C is incorrect because instructing the client to stop taking antiretroviral medications at 32 weeks of gestation is not mentioned as an action that should be included in the plan of care for a client who is pregnant and has HIV in my sources.

Choice D is incorrect because administering a pneumococcal immunization to the newborn within 4 hours following birth is not mentioned as an action that should be included in the plan of care for a client who is pregnant and has HIV in my sources.

(A) "Your partner will apply continuous, firm pressure between your thumb and index finger": This statement is not appropriate for describing counterpressure during labor. Counterpressure typically involves applying pressure to areas such as the lower back or sacrum, not between the thumb and index finger.

(B) "Your partner will apply pressure to the top of your uterus during contractions": This statement is not appropriate. Applying pressure to the top of the uterus during contractions could be harmful and is not recommended as a counterpressure technique during labor. Counterpressure is generally applied to the lower back or hips to alleviate pain.

(C) "Your partner will apply steady pressure with a tennis ball to your finger": This statement is not correct. Counterpressure during labor involves applying pressure to the lower back or hips, not to the fingers. A tennis ball may be used, but it is applied to the lower back or sacral area, not the fingers.

Choice B is incorrect because French fries are not a food that the nurse should recommend for a client who is at 32 weeks of gestation and has cholelithiasis to include in her diet.
Unhealthy fats, like those often found in fried foods, should be avoided.

Choice C is incorrect because whole milk is not a food that the nurse should recommend for a client who is at 32 weeks of gestation and has cholelithiasis to include in her diet.

Unhealthy fats, like those often found in whole milk, should be avoided.

Choice D is incorrect because a bacon cheeseburger is not a food that the nurse should recommend for a client who is at 32 weeks of gestation and has cholelithiasis to include in her diet.
Unhealthy fats, like those often found in bacon and cheeseburgers, should be avoided.

Choice B is incorrect because warm water can increase blood flow and may
worsen engorgement.

Choice C is incorrect because a supportive bra can help reduce discomfort from
engorgement.

Choice D is incorrect because pumping can stimulate milk production and may worsen engorgement.

Choice A is incorrect because the heel should be punctured on the outer aspect of the foot to avoid damaging the calcaneus bone.

Choice C is incorrect because the heel should be cleansed with an alcohol swab
before, not after, the procedure.

Choice D is incorrect because there is no need to place an ice pack on the newborn’s heel before the procedure.

Choice B is not the answer because subconjunctival hemorrhage in a newborn is usually normal and harmless.
It may be caused by pressure changes during vaginal delivery and will disappear on its own after two or three weeks.

Choice C is not the answer because single palmar creases develop while a baby
is growing in the womb and appear in about 1 out of 30 people.
While some single palmar creases may indicate problems with development and be linked with certain disorders, it is not necessarily a cause for concern.

Choice D is not the answer because transient circumoral cyanosis refers to blue discoloration around the mouth only and is usually seen in infants.
It’s often considered a type of acrocyanosis which happens when small blood vessels shrink in response to cold.
This is very normal in infants during the first few days after birth.

Choice A is incorrect because magnesium sulfate is used to treat hypertension
associated with preeclampsia.

Choice B is incorrect because a respiratory rate of 16/min is within normal
range.

Choice D is incorrect because hyperglycemia is not a known adverse reaction to magnesium sulfate.

Choice B is incorrect because a persistent headache is not a known symptom of placenta previa.

Choice C is incorrect because uterine hypertonicity is not a known symptom of placenta previa.

Choice D is incorrect because a firm, rigid abdomen is not a known symptom of placenta previa.