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 .
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Providing the newborn with 15 mL glucose water after each feeding is not a recommended action for a newborn undergoing phototherapy for jaundice. While maintaining adequate hydration is important, feedings should consist of breast milk or formula, unless otherwise directed by a healthcare provider.
Choice B rationale
Before starting phototherapy, it’s important to protect the newborn’s eyes from the light by applying eye patches. This can help prevent potential damage to the retinas.
Choice C rationale
Applying hydrating lotion to the newborn’s skin prior to treatment is not a recommended action for a newborn undergoing phototherapy for jaundice. The light needs to be able to penetrate the skin in order to break down the bilirubin, and applying lotion could potentially interfere with this process.
Choice D rationale
Turning the newborn every hour is not a recommended action for a newborn undergoing phototherapy for jaundice. While it’s important to change the newborn’s position regularly to ensure that all areas of the skin are exposed to the light, this does not need to be done on an hourly basis.
Correct Answer is A
Explanation
Consuming foods served at cool temperatures can help alleviate nausea and vomiting during early pregnancy. Cold foods often have less aroma compared to hot foods, which can make them more tolerable for someone experiencing nausea.
Choice B rationale
Brushing teeth after each meal is a good oral hygiene practice, but it does not directly help with managing nausea and vomiting during early pregnancy.
Choice C rationale
Eating three large meals per day is not recommended for managing nausea and vomiting during early pregnancy. Instead, eating small, frequent meals throughout the day can help keep the stomach from becoming empty, which can exacerbate nausea.
Choice D rationale
Drinking plenty of water when feeling nauseated can help prevent dehydration, which can occur as a result of vomiting. However, it may not directly alleviate the feeling of nausea.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.