A client who is 2 days postpartum has a saturated perineal pad with bright red lochia containing small clots. What should the nurse document in the client's medical record?

Correct Answer: A

Rationale: The correct answer is A: Moderate lochia rubra. This indicates normal postpartum bleeding 2 days after delivery. Bright red lochia with small clots is expected at this stage. Excessive lochia serosa (B) and scant lochia serosa (D) are not appropriate as serosa typically appears after the first few days postpartum. Light lochia rubra (C) does not accurately describe the amount of bleeding observed in this scenario.

Correct Answer: C

Rationale: Rationale: - MSAFP screening is recommended for all pregnant clients to assess risk of neural tube defects or chromosomal abnormalities. - It is a standard prenatal test regardless of specific medical conditions. - Options A, B, and D are not directly related to the indication for MSAFP screening in pregnancy.

Correct Answer: D

Rationale: The correct answer is D: Wide skull sutures. Small for gestational age (SGA) newborns may have wide skull sutures due to reduced skull growth in utero. This is because their growth was restricted, leading to smaller head size and delayed closure of skull sutures. A, B, and C are incorrect: A: Moist skin is not a typical finding associated with being small for gestational age. B: Protruding abdomen is more commonly seen in conditions like gastroschisis or omphalocele, not necessarily SGA. C: Gray umbilical cord color is not specifically linked to being small for gestational age.

Correct Answer: D

Rationale: The correct answer is D: Position the newborn skin-to-skin on the client's chest. This promotes bonding through touch, warmth, and smell, stimulating the release of oxytocin in both the parent and the infant. Skin-to-skin contact enhances attachment, regulates the newborn's temperature and breathing, and supports breastfeeding initiation. A: Encouraging parents to touch and explore the newborn's features is important but not as crucial as immediate skin-to-skin contact for bonding and physiological benefits. B: Limiting noise and interruptions can create a calm environment but does not directly promote bonding like skin-to-skin contact. C: Placing the newborn at the client's breast is beneficial for breastfeeding initiation but may not provide the same level of closeness and comfort as skin-to-skin contact.

Correct Answer: C

Rationale: The correct answer is C. Cleaning the penis with each diaper change is crucial for proper circumcision care to prevent infection. This statement shows understanding of the teaching as it emphasizes the importance of keeping the area clean. A: The circumcision healing within a couple of days is incorrect as it usually takes about 1-2 weeks. B: Not removing the yellow mucus can lead to infection, so this is an incorrect statement. D: Giving a tub bath within a couple of days can increase the risk of infection, so this statement is incorrect.

Correct Answer: D

Rationale: The correct answer is D - Measure leg circumferences. This is important in assessing for changes in swelling, which can indicate worsening thrombophlebitis. Monitoring leg circumferences helps in early detection of complications like deep vein thrombosis. Applying cold compresses (A) can worsen vasoconstriction, massage (B) can dislodge clots, and allowing ambulation (C) can increase the risk of clot migration.

Correct Answer: A

Rationale: The correct answer is A: This is more commonly seen in newborns who have dark skin. The bluish-brown marking described is likely a Mongolian spot, a common birthmark in darker-skinned infants. It is not related to hyperbilirubinemia (jaundice), forceps marks, or birth trauma. Mongolian spots are benign and typically fade over time. This statement is correct as it addresses the specific characteristic of the marking and its association with dark skin pigmentation in newborns.

Correct Answer: B

Rationale: The correct answer is B because it demonstrates the client's understanding that a second vaccination is needed, which is crucial for developing adequate immunity against varicella. This statement shows comprehension of the vaccination schedule and the importance of completing the series for full protection. Option A is incorrect as it suggests the need for a second vaccination but lacks conviction. Option C is incorrect because it only states the purpose of the vaccine without addressing the need for a second dose. Option D is incorrect as it mentions testing for immunity status, which is not typically necessary after receiving the varicella vaccine.

Correct Answer: C

Rationale: The correct answer is C: Erythromycin. Erythromycin is the standard treatment for preventing ophthalmia neonatorum, a condition caused by Neisseria gonorrhoeae or Chlamydia trachomatis. It is a broad-spectrum antibiotic that effectively prevents bacterial infections in newborns. Ofloxacin (A) is a fluoroquinolone antibiotic not typically used in newborns. Nystatin (B) is an antifungal medication used for treating fungal infections, not bacterial infections like ophthalmia neonatorum. Ceftriaxone (D) is a cephalosporin antibiotic used for various bacterial infections, but it is not the first-line treatment for preventing ophthalmia neonatorum.