A nurse is assessing a client who is 1 hour postpartum.
Which of the following findings should the nurse report to the provider?
Temperature 37.7° C (99.9° F).
Boggy fundus.
Lochia rubra with small clots.
Minimal perineal edema.
The Correct Answer is B
Choice A rationale
A temperature of 37.7° C (99.9° F) in the immediate postpartum period is a relatively common and often benign finding, typically within normal limits or indicating mild dehydration or exertion from labor. A slight elevation is not usually a cause for immediate concern unless accompanied by other signs of infection, which would warrant further investigation. Normal range is 36.5° C to 37.5° C (97.7° F to 99.5° F).
Choice B rationale
A boggy fundus is a significant finding that the nurse should report immediately. A boggy, soft uterus indicates uterine atony, which means the uterine muscles are not contracting effectively. This significantly increases the risk of postpartum hemorrhage due to inadequate compression of uterine blood vessels.
Choice C rationale
Lochia rubra with small clots is considered a normal finding in the immediate postpartum period. Lochia rubra is the initial dark red discharge consisting of blood, decidual tissue, and mucus. Small clots are expected as blood clots and detaches from the uterine wall, reflecting normal uterine involution.
Choice D rationale
Minimal perineal edema is a normal and expected finding after vaginal delivery. The trauma of childbirth often results in some degree of swelling in the perineal area. "Minimal" edema indicates that the swelling is not excessive and does not suggest a complication requiring immediate reporting to the provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A,B"},"C":{"answers":"A"},"D":{"answers":"A,B"}}
Explanation
Abruptio Placentae: Typically does not cause increased contraction frequency; contractions may be normal or decreased due to uterine irritation or pain.
Uterine Tachysystole: Characterized by more than 5 contractions in 10 minutes averaged over 30 minutes, indicating excessive contraction frequency, which can reduce uteroplacental perfusion.
Uterine Tone
Abruptio Placentae: The uterus often becomes firm, rigid, and tender due to bleeding and inflammation caused by premature placental separation, increasing baseline uterine tone.
Uterine Tachysystole: Uterine tone is elevated because contractions are prolonged and close together, causing the uterus to remain tense with insufficient relaxation.
Pain Report
Abruptio Placentae: Patients usually report sharp, severe abdominal or back pain due to the sudden placental detachment and uterine irritation.
Uterine Tachysystole: Pain may be present but is typically related to frequent contractions rather than sharp, localized pain.
FHR Pattern
Abruptio Placentae: Commonly causes fetal heart rate abnormalities like late decelerations, bradycardia, or absent variability due to fetal hypoxia from compromised placental perfusion.
Uterine Tachysystole: Can cause decreased fetal heart rate variability and late decelerations because frequent contractions reduce oxygen delivery during inadequate relaxation.
Correct Answer is A
Explanation
Choice A rationale
A prolonged period of absent FHR variability is a critical finding that the nurse must report to the provider immediately. Absent variability indicates a significant lack of fetal well-being, potentially due to severe hypoxia, acidosis, or neurological compromise. It necessitates prompt intervention to prevent adverse outcomes.
Choice B rationale
An FHR increase to 150/min is within the normal fetal heart rate range, which typically falls between 110 and 160 beats per minute. This finding alone does not indicate a problem and would not require reporting to the provider, as it suggests adequate fetal oxygenation and an appropriately reactive fetus.
Choice C rationale
FHR accelerations of 15/min for 15 seconds are a positive sign of fetal well-being. Accelerations indicate an intact fetal nervous system and adequate oxygenation. They are a reassuring finding and suggest that the fetus is tolerating the labor process well, therefore not requiring reporting.
Choice D rationale
Early decelerations of the FHR are typically benign and do not require reporting to the provider. These decelerations are usually associated with head compression during contractions and are characterized by a gradual decrease in FHR that mirrors the contraction, indicating a physiological response.
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.
