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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Betamethasone is a corticosteroid used in the prepartum period to promote fetal lung maturity. This reduces the risk of neonatal respiratory distress in babies likely to be delivered before term A, B, D- betamethasone has no effect on preterm labor contractions, increase fetal heart rate, or halt cervical dilation.
Correct Answer is D
Explanation
Small for gestational age (SGA) newborns are at risk of hypoglycemia due to decreased glycogen stores and limited fat reserves. Therefore, monitoring blood glucose levels is essential to detect and promptly intervene in case of hypoglycemia.
A, B, C- monitoring other parameters such as vital signs, axillary temperature and weight are important aspects of newborn care but not specific to SGA newborns.
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