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

Answer and Explanation

The Correct Answer is C

Choice A rationale
A fundus at the level of the umbilicus is a normal finding for a woman who is 4 hours postpartum.
Choice B rationale
Deep tendon reflexes of 4+ could indicate hyperreflexia, a sign of preeclampsia, but this is not the priority if the client has a saturated perineal pad in 30 minutes.
Choice C rationale
A saturated perineal pad in 30 minutes indicates heavy bleeding, which could be a sign of postpartum hemorrhage. This is a life-threatening condition and is therefore the priority.
Choice D rationale
Approximated edges of the episiotomy is a normal finding in a woman who is 4 hours postpartum.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A rationale
Elevating the client’s legs is not the first action to take. While it can help with circulation, it does not directly address the issue of late decelerations.
Choice B rationale
Administering oxygen using a nonrebreather mask can be beneficial as it can increase the amount of oxygen available to the fetus. However, it is not the first action to take.
Choice C rationale
Placing the client in the lateral position is the correct action. This position can help improve placental blood flow and potentially improve the oxygen supply to the fetus.
Choice D rationale
Increasing the rate of maintenance IV infusion is not the first action to take. While it can help maintain hydration and blood pressure, it does not directly address the issue of late decelerations.

A. A cesarean section will be necessary if vaginal lesions are present at the time of labor. B. Sitz baths need to be taken every 4 hours while awake if vaginal lesions are present. C. The newborn will be observed and treated in the neonatal intensive care unit. D. Total abstinence from sexual intercourse is necessary during the entire pregnancy. E. Administer Valacyclovir daily after 36 weeks of pregnancy

Correct Answer is ["A","E"]

Explanation

Choice A rationale
A cesarean section will be necessary if vaginal lesions are present at the time of labor. This is to prevent the transmission of the herpes virus to the baby during delivery, which can lead to serious complications such as neonatal herpes, a potentially deadly infection.
Choice B rationale
While sitz baths can help alleviate the discomfort caused by genital herpes lesions, they do not directly protect the fetus from herpes infection. The primary purpose of sitz baths in this context is to provide symptomatic relief to the mother.

Choice C rationale
The newborn will not necessarily be observed and treated in the neonatal intensive care unit just because the mother has genital herpes. The need for neonatal intensive care would depend on various factors, including whether the baby contracts the virus during delivery.
Choice D rationale
Total abstinence from sexual intercourse is not necessary during the entire pregnancy. However, it is recommended to abstain from sexual intercourse during active outbreaks to reduce the risk of transmission.
Choice E rationale
Daily administration of Valacyclovir (Valtrex) is necessary after the 36th week of pregnancy. This is known as suppressive therapy, which can help reduce the risk of an outbreak at the time of delivery and thereby reduce the risk of transmitting the virus to the baby.

View Question and Answer

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

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A nurse is providing instructions to a pregnant client with genital herpes about the measures that are needed to protect the fetus. What information should the nurse give to the client?

Correct Answer is ["A","E"]

Explanation

A nurse is admitting a client who is at 37 weeks of gestation and has severe gestational hypertension. Which of the following actions should the nurse expect to implement? (Select all that apply)

A nurse is caring for a client who is 2 hours postpartum following a vaginal birth. Which of the following findings indicates the client’s bladder is distended?

A nurse is caring for a client who is gravida 3, para 2, and is in active labor. The fetal head is at 3+ station after a vaginal examination.Which of the following actions should the nurse take?

A nurse is performing a physical examination of a client who is 1 day postpartum. Which finding requires immediate attention?

A nurse is preparing to administer 250 mg of an antibiotic intramuscularly to a pregnant client for a sexually transmitted infection. The available medication is 3 g/5 mL. How many mL should the nurse administer per dose? (This is a medical math querry no options provided) .

A nurse is educating the mother of a newborn who was born small for gestational age. Which of the following should the nurse mention as a potential cause of this condition?

A nurse is attending to a client who is a first-time mother, at term, and experiencing contractions. She is uncertain if she is in labor.Which of the following would the nurse identify as an indication of true labor?

A nurse is caring for a client who is 42 weeks of gestation. Exhibits Based on the updated assessment findings, which of the following actions should the nurse plan to take? Click to specify whether the nurse’s planned actions are anticipated, nonessential, or contraindicated.