A nurse is assessing a client who is 4 hours postpartum following a vaginal delivery. Which of the following findings should the nurse identify as the priority?
Fundus at the level of the umbilicus
Deep tendon reflexes 4+
Saturated perineal pad in 30 minutes
Approximated edges of the episiotomy
None
None
The Correct Answer is B
Choice A rationale: Fundus at umbilicus is expected 4 hours postpartum, indicating normal uterine involution. No abnormal bleeding or uterine atony is implied, so it’s not a priority concern.
Choice B rationale: Deep tendon reflexes 4+ are hyperactive and signal increased neuromuscular irritability, placing the client at high risk for seizures due to preeclampsia. Immediate magnesium sulfate therapy may be required.
Choice C rationale: Saturated pad in 30 minutes suggests heavy lochia but is not yet classified as hemorrhage. Requires monitoring, but seizure risk from preeclampsia is more immediately life-threatening.
Choice D rationale: Approximated episiotomy edges indicate proper healing and no infection or dehiscence. This is a normal finding and does not require urgent intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A,B"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"B"}}
Explanation
• Frequent urination: This is more likely to be associated with a UTI, as frequent urination is a common symptom of UTIs.
• Low back pain: This can be associated with both preterm labor and a UTI. Low back pain can be a sign of labor, and it can also be a symptom of a UTI.
• Temperature of 38.3°C (101°F): This is more likely to be associated with a UTI, as fever is a common symptom of infections, including UTIs.
• Strong urge to push: This is more likely to be associated with preterm labor, as an urge to push can be a sign of labor.
• Contractions every 1.5 minutes: This is more likely to be associated with preterm labor, as frequent contractions are a sign of labor.
• Pain level of 8 on a scale of 0 to 10: This can be associated with both preterm labor and a UTI. Severe pain can be a sign of labor, and it can also be a symptom of a UTI. Please note that these are potential associations and the healthcare provider should be informed immediately for further evaluation and management. It’s important to continue following the provider’s prescriptions and closely monitor the client’s condition.
Correct Answer is A
Explanation
At the level of the umbilicus. After a vaginal delivery, the nurse should expect to find the uterine fundus at the level of the umbilicus.
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