Two days after delivery, a postpartum client prepares for discharge. What should the nurse teach her about lochia flow?
Incorrect: Lochia does change color but goes from lochia rubra (bright red) on days 1-3, to lochia serosa (pinkish brown) on days 4-9, to lochia alba (creamy white) days 10-21.
...
1. Two days after delivery, a postpartum client prepares for discharge. What should the nurse
teach her about lochia flow?
Incorrect: Lochia does change color but goes from lochia rubra (bright red) on days 1-3, to
lochia serosa (pinkish brown) on days 4-9, to lochia alba (creamy white) days 10-21.
Incorrect: Numerous clots are abnormal and should be reported to the physician.
Incorrect: Saturation of the perineal pad is considered abnormal and may indicate postpartum
hemorrhage.
Correct: Lochia normally lasts for about 21 days, and changes from a bright red, to
pinkish brown, to creamy white.
The color of the lochia changes from a bright red to white after four days
Numerous large clots are normal for the next three to four days
Saturation of the perineal pad with blood is expected when getting up from the bed
Lochia should last for about 3 weeks, changing color every few days
2. A nurse monitors fetal well-being by means of an external monitor. At the peak of the
contractions, the fetal heart rate has repeatedly dropped 30 beats/min below the baseline. Late
decelerations are suspected and the nurse notifies the physician. Which is the rationale for
this action?
Incorrect: A nuchal cord (cord around the neck) is associated with variable decelerations, not
late decelerations.
Incorrect: Variable decelerations (not late decelerations) are associated with cord
compression.
Incorrect: Late decelerations are a result of hypoxia. They are not reflective of the strength of
maternal contractions.
Correct: Late decelerations are associated with uteroplacental insufficiency and are a
sign of fetal hypoxia. Repeated late decelerations indicate fetal distress.
The umbilical cord is wrapped tightly around the fetus' neck
The fetal cord is being compressed due to rapid descent of the fetal head
Maternal contractions are not adequate enough to deliver the fetus
, The fetus is not receiving adequate oxygen and is in distress
3. Which preoperative nursing interventions should be included for a client who is scheduled
to have an emergency cesarean birth?
Incorrect: Monitoring O2 saturations and administering pain medications are postoperative
interventions.
Incorrect: Taking vital signs every 15 minutes is a postoperative intervention. Instructing the
client regarding breathing exercises is not appropriate in a crisis situation when the client's
anxiety is high, because information would probably not be retained. In an emergency, there
is time only for essential interventions.
Correct: Because this is an emergency, surgery must be performed quickly. Anxiety of
the client and the family will be high. Inserting an indwelling catheter helps to keep the
bladder empty and free from injury when the incision is made.
Incorrect: The nurse should have assessed breath sounds upon admission. Breath sounds are
important if the client is to receive general anesthesia, but the anesthesiologist will be
listening to breath sounds in surgery in that case.
Monitor oxygen saturation and administer pain medication.
Assess vital signs every 15 minutes and instruct the client about postoperative care.
Alleviate anxiety and insert an indwelling catheter.
Perform a sterile vaginal examination and assess breath sounds.
4. Which nursing instruction should be given to the breastfeeding mother regarding care of
the breasts after discharge?
Incorrect: Engorgement occurs on about the third or fourth postpartum day and is a
result of the breast milk formation. The primary way to relieve engorgement is by
pumping or longer nursing. Giving a bottle of formula will compound the problem
because the baby will not be hungry and will not empty the breasts well.
Incorrect: Applying lotion to the nipples is not effective for keeping them soft. Excessive
amounts of lotion may harbor microorganisms.
Correct: In order to stimulate adequate milk production, the breasts should be pumped
if the infant is not sucking or eating well, or if the breasts are not fully emptied.
Incorrect: Using soap on the breasts dries the nipples and can cause cracking.
The baby should be given a bottle of formula if engorgement occurs.
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