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
Category | ATI EXAM |
Comments | 0 |
Rating | |
Sales | 0 |