A nurse is assessing a client who is 1 hr postpartum. Which of the following findings should the nurse report to the provider?
Lochia rubra with small clots
Minimal perineal edema
Boggy fundus
Temperature 37.7° C (99.9° F)
The Correct Answer is C
. Lochia rubra with small clots:
Lochia rubra is the normal vaginal discharge occurring after childbirth, consisting of blood, mucus, and uterine tissue. It is expected for lochia to be present in the immediate postpartum period, and small clots are also considered normal as long as they are not excessive in size. Therefore, this finding is within the expected range for a client who is 1 hour postpartum and does not require immediate reporting to the provider.
B. Minimal perineal edema:
Perineal edema, or swelling in the perineal area, can be common after childbirth, particularly following vaginal delivery or if there was perineal trauma during labor. Some degree of perineal edema is generally expected in the immediate postpartum period and may resolve with time and appropriate care. As long as the edema is minimal and not causing significant discomfort or obstructing the assessment, it is not typically a cause for immediate concern or reporting to the provider.
C. Boggy fundus:
A boggy fundus refers to a uterus that feels soft and mushy instead of firm and well-contracted. It suggests uterine atony, which is a significant concern in the postpartum period as it can lead to excessive bleeding and postpartum hemorrhage. Therefore, a boggy fundus should be reported promptly to the provider so that interventions can be initiated to address the uterine atony and prevent complications.
D. Temperature 37.7°C (99.9°F):
A temperature of 37.7°C (99.9°F) is slightly elevated but may still fall within the normal range for the immediate postpartum period. While fever can indicate infection, a single temperature reading alone may not be sufficient to confirm an infection. It is important for the nurse to continue monitoring the client's temperature and assess for other signs and symptoms of infection before reporting to the provider. Therefore, this finding does not necessarily warrant immediate reporting unless accompanied by other concerning symptoms suggestive of infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Depressed anterior fontanel:
A depressed anterior fontanel is not typically associated with forceps-assisted birth. The fontanelles may become depressed in conditions such as dehydration or if the newborn is in a hypovolemic state, but it is not directly related to forceps use during delivery.
B. Epicanthal folds:
Epicanthal folds are normal anatomical features that are commonly seen in newborns, especially those of certain ethnic backgrounds. They are not indicative of an injury caused by forceps.
C. Facial asymmetry:
Facial asymmetry can occur as a result of forceps application during birth. The forceps' pressure on the baby's face can cause bruising, swelling, or even facial nerve injury, leading to temporary or permanent facial asymmetry.
D. Uneven gluteal skinfolds:
Uneven gluteal skinfolds are not typically associated with forceps-assisted birth. This finding is more commonly seen in conditions such as hip dysplasia or developmental dysplasia of the hip (DDH), and it is not directly related to forceps use during delivery.
Correct Answer is D
Explanation
. A client who reports lochia rubra requiring changing perineal pads every 3 hr:
This finding is consistent with normal postpartum lochia patterns, particularly in the early postpartum period. Lochia rubra is the initial bright red vaginal discharge that occurs after childbirth, and changing perineal pads every 3 hours is within the expected range. There is no immediate concern requiring notification of the provider for this client.
B. A client who reports abdominal cramping during breastfeeding:
Abdominal cramping during breastfeeding, also known as afterpains, is a common occurrence in the postpartum period, especially for multiparous clients. These cramps are caused by the release of oxytocin during breastfeeding and help the uterus to contract and return to its pre-pregnancy size. While uncomfortable, afterpains are considered normal and do not typically require notification of the provider unless they are severe or accompanied by other concerning symptoms.
C. A client who has a urinary output of 300 mL in 8 hr:
This urinary output is below the expected range for a postpartum client, and it may indicate inadequate fluid intake, urinary retention, or other issues. While it is important to monitor urinary output and address any potential concerns, this finding alone may not require immediate notification of the provider. However, continued monitoring and assessment are warranted to ensure adequate urinary function.
D. A client who is receiving magnesium sulfate and has absent deep tendon reflexes:
Absent deep tendon reflexes are an indication of magnesium toxicity, which is a serious complication of magnesium sulfate administration. Magnesium sulfate is commonly used to prevent seizures in clients with preeclampsia or eclampsia. However, excessive levels of magnesium can lead to respiratory depression, cardiac arrest, and other adverse effects. Absent deep tendon reflexes are an early sign of magnesium toxicity and require immediate intervention, including discontinuation of magnesium sulfate and close monitoring of the client's respiratory and cardiac status. Therefore, the nurse should notify the provider immediately for further guidance and management.
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