During ambulation to the bathroom, a postpartum client experiences a gush of dark red blood that soon stops. On data collection, 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?

Correct Answer: C

Rationale: The correct answer is C: A normal postpartum discharge of lochia. This finding indicates a normal postpartum process. Lochia is the vaginal discharge after childbirth consisting of blood, mucus, and uterine tissue. The gush of dark red blood followed by cessation is typical of lochia rubra, the initial stage of postpartum bleeding. The firm, midline, and well-positioned uterus indicates proper involution. Choices A and B are incorrect as the firm uterus rules out hematoma or laceration. Choice D is incorrect as the amount of bleeding described is within the normal range for postpartum lochia.

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: B

Rationale: The correct answer is B: Rooting. This reflex helps the newborn turn their head towards a stimulus, such as the mother's nipple, facilitating latching during breastfeeding. Babinski (A) is a reflex related to the sole of the foot, Moro (C) is a startle reflex, and Stepping (D) involves movements resembling walking. These reflexes do not directly support the latch during breastfeeding. Rooting reflex is the most relevant and essential reflex for successful breastfeeding initiation.

Correct Answer: B

Rationale: The correct answer is B: Suction the mouth with a bulb syringe. This is the priority action because secretions in the mouth can obstruct the airway and lead to respiratory distress. Suctioning the mouth first helps clear the airway effectively. Suctioning the nose with a bulb syringe (choice A) may not address the immediate risk of airway obstruction. Using a suction catheter with low negative pressure (choice C) can be too strong for a newborn. Turning the newborn on their side (choice D) may not effectively address the airway obstruction from secretions in the mouth.

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: 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: 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: C

Rationale: The correct answer is C. Tilt the bottle to prevent air from entering as the baby sucks is incorrect. It is important not to tilt the bottle as it can cause the baby to swallow air, leading to gas and discomfort. A: Keeping the baby's head elevated helps prevent choking. B: Allowing the baby to burp reduces gas and discomfort. D: Soft, formed yellow stools indicate a healthy digestive system. Thus, C is the only statement that may lead to issues and requires further instruction.

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.