2024 ATI MATERNAL NEWBORN NURSING EDITION 10, UNIT 3 POSTPARTUM NURSING CARE QUESTIONS AND CORRECT ANSWERS A nurse is performing a fundal assessment for a client who is 2 days postpartum and observes the perennial pad for lochia. She notes the pad to be saturated approximately 12 cm with lochia that is bright red and contains small clots. Which of the following findings should the nurse document? a. moderate lochia rubra b. Excessive blood loss c. light lochia rubra d. Scant lochia serosa - Answer -a a. CORRECT: the client has moderate lochia rubra containing small clots, which is an expected finding for the second day postpartum. b. . Excessive blood loss is saturation of a perineal pad in 15 min or less or pooling of blood under the client's buttocks. c. light lochia rubra is a perineal pad that is saturated less than 10 cm with lochia. d. scant lochia serosa (less than 2.5 cm on perineal pad) is pinkish brown in color and serosanguineous in consistency. it occurs on day 4 to 12 following delivery." 2. During ambulation to the bathroom, a postpartum client experiences a gush of dark red blood that soon stops. on assessment, a nurse finds the uterus to be firm, midline, and at the level of the umbilicus. Which of the following findings should the nurse interpret this data as being? a. Evidence of a possible vaginal hematoma b. an indication of a cervical or perineal laceration c. A normal postural discharge of lochia d. Abnormally excessive lochia rubra flow - Answer -c a. a client who has a vaginal hematoma is expected to report excessive pain or vaginal pressure. b. Excessive spurting of bright red blood from the vagina indicates a possible cervical or perineal laceration. c. CORRECT: lochia typically trickles from the vaginal opening but flows more steadily during uterine contractions. massaging the uterus or ambulation can result in a gush of lochia with the expression of clots and dark blood that has been pooled in the vagina, but it should soon decrease back to a trickle of bright red lochia in the early puerperium. d. Excessive blood loss consists of one pad saturated in 15 min or less or the pooling of blood under the buttocks, which is not affected by the client's postural changes." 3. A nurse is completing postpartum discharge teaching to a client who had no immunity to varicella and was given varicella vaccine. Which of the following statements by the client indicates understanding of the teaching? a. “I will need to use contraception for 3 months before considering pregnancy." b. “I need a second vaccination at my postpartum visit." c. “I was given the vaccine because my baby is o-positive." d. “I will be tested in 3 months to see if i have developed immunity." – Answer - b a. a client is instructed to not get pregnant for 1 month following administration of varicella vaccine. b. CORRECT: a second varicella immunization is needed at 4 to 8 weeks following delivery by clients who had no history of immunity. c. rho(d) immune globulin is administered to a Rh-negative mother who has an Rh -positive newborn.
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