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

The first action the nurse should take when caring for a client who has bladder distention following a vaginal birth is to assist the client to the bathroom. Bladder distention can occur after birth due to the pressure on the bladder during labour and birth.

Encouraging the client to empty her bladder will relieve the distention and promote comfort.

A. May 13 B. May 20 C. May 17 D. May 2

Correct Answer is C

Explanation

To calculate the estimated date of delivery using Nägele’s Rule, subtract three months from the first day of the last menstrual period (August 10), and then add seven days. This gives an estimated date of delivery of May 176.

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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 caring for a client who has bladder distention following a vaginal birth. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

A nurse is calculating the estimated date of delivery for a client who reports that the first day of her last menstrual period was August 10. Using Nägele’s Rule, which of the following is the client’s estimated date of delivery?

Correct Answer is C

Explanation

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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.