Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client who is 4 hr postpartum. The nurse finds a small amount of lochia rubra on the client's perineal pad. The fundus is midline and firm at the umbilicus. Which of the following actions should the nurse take?
A. Increase the rate of IV fluids.
Increasing the rate of the IV fluids is not necessary because the client's fundus is firm and midline, indicating that the uterus is contracting well and preventing excessive bleeding.
B. Assist the client to ambulate.
Assisting the client to ambulate is not advisable because it can increase the lochia flow and cause fainting or dizziness due to blood loss.
C. Perform fundal massage.
Performing fundal massage is not indicated because the fundus is already firm and midline, meaning that the uterus is adequately contracted. Massaging a firm fundus can cause pain and discomfort to the client.
D. Check for blood under the client's buttock.
Check for blood under the client's buttock. This is because lochia rubra is the normal vaginal discharge that occurs after childbirth, consisting of blood, mucus, and tissue from the placenta and the uterus lining. It is usually heavy for the first three to four days and can pool under the client's buttocks if they are lying down. Checking for blood under the buttock can help assess the amount of bleeding and prevent complications such as infection or hemorrhage.
This question is an excerpt from Nurse Dive's nursing test bank - Postpartum AMD Newborn Care Proctored Exam. Take the full exam now
Full Explanation
Check for blood under the client's buttock. This is because lochia rubra is the normal vaginal discharge that occurs after childbirth, consisting of blood, mucus, and tissue from the placenta and the uterus lining. It is usually heavy for the first three to four days and can pool under the client's buttocks if they are lying down. Checking for blood under the buttock can help assess the amount of bleeding and prevent complications such as infection or hemorrhage.
The other choices are not correct for the following reasons:
A. Increasing the rate of the IV fluids is not necessary because the client's fundus is firm and midline, indicating that the uterus is contracting well and preventing excessive bleeding.
B. Assisting the client to ambulate is not advisable because it can increase the lochia flow and cause fainting or dizziness due to blood loss.
C. Performing fundal massage is not indicated because the fundus is already firm and midline, meaning that the uterus is adequately contracted. Massaging a firm fundus can cause pain and discomfort to the client.
Similar Questions
A nurse is teaching a new mother about signs of effective breastfeeding of her newborn. Which of the following information should the nurse include in the teaching?
A. Expect your baby to feed constantly the first week of life.
This is incorrect because your baby does not need to feed constantly in the first week of life. Your baby should feed at least eight times in 24 hours but may have periods of cluster feeding where they feed more frequently for a few hours.
B. Your baby can lose 5% of body weight during the first 3 days of life.
Your baby can lose 5% of body weight during the first 3 days of life. This is a normal physiological process that happens as your baby adjusts to breastfeeding and expels excess fluids. Your baby should regain this weight by 10 to 14 days of age.
C. Expect your baby to have less than 5 wet diapers per day after the fourth day of life.
This is incorrect because your baby should have more than 5 wet diapers per day after the fourth day of life. This is a sign that your baby is getting enough milk and is well-hydrated.
D. Your baby should gain 0.25 oz (7 grams) per day after the fourth day of life.
This is incorrect because your baby should gain more than 0.25 oz (7 grams) per day after the fourth day of life. The average weight gain for a breastfed baby is about 0.5 to 1 oz (14 to 28 grams) per day in the first month.
Full Explanation
Your baby can lose 5% of body weight during the first 3 days of life. This is a normal physiological process that happens as your baby adjusts to breastfeeding and expels excess fluids. Your baby should regain this weight by 10 to 14 days of age.
Choice A is incorrect because your baby does not need to feed constantly in the first week of life. Your baby should feed at least eight times in 24 hours but may have periods of cluster feeding where they feed more frequently for a few hours.
Choice C is incorrect because your baby should have more than 5 wet diapers per day after the fourth day of life. This is a sign that your baby is getting enough milk and is well-hydrated.
Choice D is incorrect because your baby should gain more than 0.25 oz (7 grams) per day after the fourth day of life. The average weight gain for a breastfed baby is about 0.5 to 1 oz (14 to 28 grams) per day in the first month.
The nurse is teaching a prenatal class and illustrating some of the basic events that will happen right after the birth. The nurse should point out which action will best help the infant maintain an adequate body temperature.
A. Turn the temperature up in the birth room.
This is not correct because turning up the temperature in the birth room may not be enough to prevent heat loss from the infant, especially if they are wet or exposed to cold surfaces. It may also make the mother uncomfortable or dehydrated.
B. Bathe the infant immediately after birth.
This is not correct because bathing the infant immediately after birth may increase heat loss from evaporation and conduction. It may also interfere with the baby's natural protective coating (vernix) and microbiome. Bathing should be delayed until at least 24 hours after birth.
C. Place the infant on the mother's abdomen after birth.
Place the infant on the mother's abdomen after birth. This will help the infant maintain an adequate body temperature by providing skin-to-skin contact with the mother, which reduces heat loss and promotes bonding. Skin-to-skin contact also stimulates the baby's natural feeding cues and helps initiate breastfeeding.
D. Wrap the infant in a warm, dry blanket.
This is not correct because wrapping the infant in a warm, dry blanket may not provide the same benefits as skin-to-skin contact with the mother. It may also prevent the baby from smelling and seeing the mother's breast, which are important cues for breastfeeding initiation.
Full Explanation
Place the infant on the mother's abdomen after birth. This will help the infant maintain an adequate body temperature by providing skin-to-skin contact with the mother, which reduces heat loss and promotes bonding. Skin-to-skin contact also stimulates the baby's natural feeding cues and helps initiate breastfeeding.
Choice A is not correct because turning up the temperature in the birth room may not be enough to prevent heat loss from the infant, especially if they are wet or exposed to cold surfaces. It may also make the mother uncomfortable or dehydrated.
Choice B is not correct because bathing the infant immediately after birth may increase heat loss from evaporation and conduction. It may also interfere with the baby's natural protective coating (vernix) and microbiome. Bathing should be delayed until at least 24 hours after birth.
Choice D is not correct because wrapping the infant in a warm, dry blanket may not provide the same benefits as skin-to-skin contact with the mother. It may also prevent the baby from smelling and seeing the mother's breast, which are important cues for breastfeeding initiation.
A nurse is caring for several newborn clients. For which of the following findings should the nurse notify the charge nurse?
A. Hematocrit of 60% in an infant who is 8-hr old.
This is wrong because a hematocrit of 60% in an infant who is 8-hr old is not abnormal. Hematocrit is the percentage of red blood cells in the blood. Newborns normally have higher hematocrit levels than older children and adults because they have more red blood cells at birth.
B. Jaundice in an infant who is 4-hr old.
Jaundice in an infant who is 4-hr old. This is because jaundice is a yellow discoloration of the skin and eyes caused by high levels of bilirubin in the blood¹. Jaundice usually appears between the second and fourth day after birth and lasts for one to two weeks². Jaundice that appears within the first 24 hours of life is considered early-onset jaundice and may indicate a serious problem, such as an infection, a blood type mismatch, or a liver disorder. The nurse should notify the charge nurse of this finding and request a blood test to check the bilirubin level.
C. Blood glucose fingerstick of 40 mg/dL for an infant who is 1-hr old.
This is wrong because a blood glucose fingerstick of 40 mg/dL for an infant who is 1-hr old is not abnormal. Blood glucose is the amount of sugar in the blood. Newborns normally have lower blood glucose levels than older children and adults because they have less glycogen (stored sugar) at birth.
D. Acrocyanosis in an infant who is 2-hr old.
This is wrong because acrocyanosis in an infant who is 2-hr old is not abnormal. Acrocyanosis is a bluish discoloration of the hands and feet caused by poor circulation. Newborns normally have acrocyanosis for the first few days of life because they are adjusting to the temperature outside the womb.
Full Explanation
Jaundice in an infant who is 4-hr old. This is because jaundice is a yellow discoloration of the skin and eyes caused by high levels of bilirubin in the blood. Jaundice usually appears between the second and fourth day after birth and lasts for one to two weeks. Jaundice that appears within the first 24 hours of life is considered early-onset jaundice and may indicate a serious problem, such as an infection, a blood type mismatch, or a liver disorder. The nurse should notify the charge nurse of this finding and request a blood test to check the bilirubin level.
Choice A is wrong because a hematocrit of 60% in an infant who is 8-hr old is not abnormal. Hematocrit is the percentage of red blood cells in the blood. Newborns normally have higher hematocrit levels than older children and adults because they have more red blood cells at birth.
Choice C is wrong because a blood glucose fingerstick of 40 mg/dL for an infant who is 1-hr old is not abnormal.
Blood glucose is the amount of sugar in the blood. Newborns normally have lower blood glucose levels than older children and adults because they have less glycogen (stored sugar) at birth.
Choice D is wrong because acrocyanosis in an infant who is 2-hr old is not abnormal. Acrocyanosis is a bluish discoloration of the hands and feet caused by poor circulation. Newborns normally have acrocyanosis for the first few days of life because they are adjusting to the temperature outside the womb.