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 D
Explanation
Choice A rationale
A newborn typically begins to void within 24 hours after birth, so not voiding within this time frame is not immediately concerning.
Choice B rationale
Acrocyanosis, or bluish discoloration of the hands and feet, is common in newborns, especially within the first few hours after birth. It is a normal finding and does not require immediate intervention.
Choice C rationale
A temperature of 37.5°C (99.5°F) is within the normal range for a newborn. Therefore, this does not require immediate attention.
Choice D rationale
Newborns typically pass meconium, the first stool, within 24 to 48 hours after birth. If a newborn has not passed meconium within 24 hours, it could indicate a problem such as meconium ileus, a complication of cystic fibrosis, or other conditions that might obstruct the bowel. This situation requires immediate attention and intervention.
Correct Answer is B
Explanation
Choice A rationale
Increased deposits of fat in the chest and shoulder area are not typically associated with respiratory distress syndrome in a term macrosomic newborn whose mother has poorly controlled type 2 diabetes.
Choice B rationale
Hyperinsulinemia is a condition in which there are excess levels of insulin circulating in the blood. In the case of a term macrosomic newborn whose mother has poorly controlled type 2 diabetes, the baby’s pancreas may produce extra insulin in response to the mother’s high blood glucose levels. This excess insulin can delay surfactant production, which is needed for lung maturation, leading to respiratory distress syndrome.
Choice C rationale
Brachial plexus injury is a type of birth injury that can occur due to the baby’s large size and difficulty being born. However, it is not the most likely cause of respiratory distress syndrome in a term macrosomic newborn whose mother has poorly controlled type 2 diabetes.
Choice D rationale
Increased blood viscosity can occur in newborns of mothers with poorly controlled diabetes due to polycythemia (an abnormally high number of red blood cells). However, this is not the most likely cause of respiratory distress syndrome in a term macrosomic newborn.
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