A nurse has been monitoring a client who gave birth vaginally 8 hours ago.

Based on the nurse’s notes at 0700 and 1100, select the three findings that necessitate immediate follow-up.

Peripheral edema 2+ in bilateral lower extremities

Blood pressure reading of 136/86 mm Hg

Lateral deviation of the uterus

Deep tendon reflexes 1+

Large amount of lochia rubra .

Answer and Explanation

Correct Answer : B,C,E

Choice A rationale
Peripheral edema 2+ in bilateral lower extremities is a common finding in the postpartum period and does not necessarily indicate a problem. It can result from the normal fluid shifts that occur after delivery.
Choice B rationale
A blood pressure reading of 136/86 mm Hg is slightly elevated and could indicate the development of postpartum hypertension, a condition that can lead to serious complications such as stroke. This finding necessitates immediate follow-up.
Choice C rationale
Lateral deviation of the uterus could indicate a full bladder, which can interfere with uterine contractions and lead to increased bleeding. This finding necessitates immediate follow-up.
Choice D rationale
Deep tendon reflexes 1+ are within normal limits and do not necessitate immediate follow-up.
Choice E rationale
A large amount of lochia rubra could indicate postpartum hemorrhage, a potentially life- threatening condition. This finding necessitates immediate follow-up.

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Correct Answer is C

Explanation

Choice A rationale
Polyuria, or excessive urination, is not typically associated with the administration of an epidural block with an opioid analgesic.
Choice B rationale
Bilateral crackles in the lungs can be a sign of a respiratory condition such as pneumonia or heart failure. However, they are not a common side effect of an epidural block with an opioid analgesic.
Choice C rationale
Hypotension, or low blood pressure, is a known side effect of epidural analgesia. This is due to the blockade of the sympathetic chain, which can contribute to hypotension. Therefore, it is important for the nurse to monitor the client’s blood pressure during the administration of an epidural block with an opioid analgesic.
Choice D rationale
Hyperglycemia, or high blood sugar, is not typically a side effect of an epidural block with an opioid analgesic. Hyperglycemia is more commonly associated with conditions such as diabetes.

A. Apply triple antibiotic ointment on your baby’s umbilical cord twice daily. B. Give your baby an immersion bath daily. C. Swaddle your baby with their legs in an extended position. D. Offer your baby a pacifier during naps if desired.

Correct Answer is D

Explanation

Choice A rationale
Applying triple antibiotic ointment on the baby’s umbilical cord is not typically recommended. The American Academy of Pediatrics advises against applying any antiseptic or antibiotic ointment to the umbilical cord stump in most cases.
Choice B rationale
Giving a newborn an immersion bath daily is not recommended. Newborns do not need daily baths, and excessive bathing can dry out their skin.
Choice C rationale
Swaddling a baby with their legs in an extended position is not recommended. This position can increase the risk of developmental dysplasia of the hip.
Choice D rationale
Offering a pacifier during naps or at bedtime can be part of a safe sleep routine for a newborn, once breastfeeding is well established.

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A nurse has been monitoring a client who gave birth vaginally 8 hours ago. Based on the nurse’s notes at 0700 and 1100, select the three findings that necessitate immediate follow-up.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing care to a client who is receiving an epidural block with an opioid analgesic. Which of the following findings should the nurse monitor as a potential adverse effect of the medication?

Correct Answer is C

Explanation

A nurse is providing discharge teaching to a postpartum client about caring for their newborn at home. Which of the following statements should the nurse make?

Correct Answer is D

Explanation

A nurse is reviewing the medical record of a client who had a vaginal delivery 3 hours ago.Which of the following findings place the client at risk for postpartum hemorrhage? (Select all that apply)

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A nurse is teaching about home safety with a client who is 2 days postpartum. Which of the following instructions should the nurse include in the teaching?

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A nurse has been monitoring a client who gave birth vaginally 8 hours ago.

Based on the nurse’s notes at 0700 and 1100, select the three findings that necessitate immediate follow-up.