A nurse is assessing a client who is 4 hr postpartum following a vaginal delivery. Which of the following findings should the nurse identify as the priority?
Fundus at level of umbilicus
Saturated perineal pad in 30 min
Approximated edges of episiotomy
Deep tendon reflexes 4+
The Correct Answer is D
A. Fundus is at level of the umbilicus is well contracted and therefore, not of concern.
B. A saturated perineal pad in 15 min or less can indicate excessive bleeding.
C. Approximated edges of episiotomy indicate proper wound repair and therefore, not of concern.
D. Deep Tendon reflexes 4+ -4+ are hyperactive and indicate the client is at greatest risk for preeclampsia and seizures; this is the priority.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The commonest risk factor for placenta abruption is hypertensive diseases in pregnancy. Hypertension can lead to alterations in the blood vessels supplying the placenta, increasing the risk of detachment.
The other are known risk factors but less common.
Correct Answer is B
Explanation
One of the signs that the bladder may be distended is when the fundus (top of the uterus) is palpable to the right of the midline. This displacement indicates that the bladder is pushing the uterus to the side, which can occur when the bladder is full and obstructing the descent of the uterus into the pelvis during the postpartum period.
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