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

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A rationale

Assisting the family to identify prior use of positive coping skills in family crises can be helpful, but it’s not the priority action in this situation.
Choice B rationale
Anticipating a prescription by the provider for an antidepressant might be necessary if the client is diagnosed with postpartum depression. However, the nurse first needs to assess the risk to the client and her newborn.
Choice C rationale
Asking the client if she has considered harming her newborn is the priority action. This question is crucial in assessing for postpartum depression and the safety of the newborn.
Choice D rationale
Reinforcing postpartum and newborn care discharge teaching is important, but it’s not the priority action when the client is expressing feelings of sadness and lack of energy.

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.

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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

A nurse in a clinic is caring for a client who is 3 weeks postpartum following the birth of a healthy newborn. The client reports feeling “down”, sad, having no energy, and wanting to cry. Which of the following is a priority action by the nurse?

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

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A nurse is providing discharge teaching to a client who is 3 days postoperative following a cesarean birth. Which of the following client statements should indicate to the nurse the teaching is effective? (Select all that apply)

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