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
Explanation
Choice A rationale
Early decelerations in the fetal heart rate (FHR) are caused by compression of the fetus’s head during a uterine contraction. This often happens during later stages of labor as the baby is descending through the birth canal. They may also occur during early labor if the baby is premature or in a breech position. This causes the uterus to squeeze the head during contractions.
Choice B rationale
Uteroplacental insufficiency is a condition where the placenta does not provide enough oxygen and nutrients to the fetus. This condition is typically associated with late decelerations in the FHR, not early decelerations.
Choice C rationale
Altered fetal cerebral blood flow is not typically associated with early decelerations in the FHR34.
Choice D rationale
Umbilical cord compression is typically associated with variable decelerations in the FHR, not early decelerations.
Correct Answer is ["B","C","E"]
Explanation
Choice A rationale
Allowing the newborn to continue crying is not recommended. Persistent crying can be a sign of discomfort or distress in the newborn, and it is important to identify and address the cause.
Choice B rationale
Swaddling the newborn in a receiving blanket can provide a sense of security and comfort, which can help soothe a crying newborn.
Choice C rationale
Carrying the newborn in a front or back pack can provide close physical contact and movement, both of which can be soothing to a crying newborn.
Choice D rationale
Keeping the newborn in the center of a large crib does not directly address the issue of persistent crying.
Choice E rationale
Taking the newborn for a ride in the car can provide soothing movement and noise, which can help calm a crying newborn.
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