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
Administering oxygen at 10 L/min via a non-rebreather mask is a common intervention for fetal distress, but it is not the first action a nurse should take when a decrease in fetal heart rate is observed.
Choice B rationale
Applying a fetal scalp electrode can provide a more accurate fetal heart rate reading, but it is an invasive procedure and is not the first action a nurse should take when a decrease in fetal heart rate is observed.
Choice C rationale
Changing the client’s position is the correct action. This is often the first intervention for a decrease in fetal heart rate because it can relieve possible compression of the umbilical cord, which can improve fetal circulation and increase the fetal heart rate.
Choice D rationale
Increasing the rate of the IV infusion can increase maternal blood volume and improve placental blood flow, but it is not the first action a nurse should take when a decrease in fetal heart rate is observed.

A. The infant needing more sleep can indicate a food allergy. B. Rice cereals can be a problem during lactation. C. Foods you eat do not affect breast milk. D. You might want to avoid eating peanuts.

Correct Answer is D

Explanation

Choice A rationale
While changes in an infant’s sleep patterns can be a sign of many issues, they are not a specific indicator of a food allergy.
Choice B rationale
Rice cereals are typically one of the first foods introduced to infants and are usually well- tolerated. They are not known to cause problems during lactation.
Choice C rationale

The foods a mother eats can affect breast milk, but they do not typically cause food allergies. Most babies can tolerate a variety of foods in a mother’s diet without any problems.
Choice D rationale
If there is a strong family history of peanut allergies, the mother might want to avoid eating peanuts while breastfeeding. However, current research suggests that early exposure to potential allergens may actually decrease the risk of developing allergies.

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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 is caring for a client who is experiencing a decrease in the fetal heart rate. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is caring for a client who is postpartum and is breastfeeding. The client states that she is concerned about dietary precautions since she has a family history of food allergies. The nurse offers which of the following responses?

Correct Answer is D

Explanation

A nurse is assisting a client who is postpartum with her first breastfeeding experience. When the client asks how much of the nipple she should put into the newborn’s mouth, which of the following responses should the nurse make?

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