The nurse assesses a client on the second postpartum day and finds a dark red discharge on the peripad. The stain appears to be about 5 inches long. Which of the following correctly describes the character and amount of lochia?

• A.Lochia alba, light
• B.Lochia serosa, heavy
• C.Lochia granulosa, heavy
• D.Lochia rubra, moderate

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Assessment of severe depression in a client reveals feelings of hopelessness, worthlessness; inability to feel pleasure; sleep, psychomotor, and nutritional alterations; delusional thinking; negative view of self; and feelings of abandonment. These clinical features of the client's depression alert the nurse to prioritize problems and care by addressing which of the following problems first:

• A.Nutritional status
• B.Impaired thinking
• C.Possible harm to self
• D.Rest and activity impairment

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A client's prenatal screening indicated that she has no immunity to rubella. She is now 10 weeks pregnant. The best time to immunize her is:

• A.In the immediate postpartum period
• B.After the first trimester
• C.At 28 weeks' gestation
• D.Within 72 hours postpartum

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The physician orders haloperidol 5 mg IM stat for a client and tells the nurse that the dose can be repeated in
1-2 hours if needed. The most likely rationale for this order is:

• A.The client will settle down more quickly if he thinks the staff is medicating him
• B.The medication will sedate the client until the physician arrives
• C.Haloperidol is a minor tranquilizer and will not oversedate the client
• D.Rapid neuroleptization is the most effective approach to care for the violent or potentially violent client

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A client with a diagnosis of C-4 injury has been stabilized and is ready for discharge. Because this client is at risk for autonomic dysreflexia, he and his family should be instructed to assess for and report:

• A.Dizziness and tachypnea
• B.Circumoral pallor and lightheadedness
• C.Headache and facial flushing
• D.Pallor and itching of the face and neck

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