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+

Answer and Explanation

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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Correct Answer is B

Explanation

Hydrocephalus is a condition characterized by the accumulation of cerebrospinal fluid (CSF) within the ventricles of the brain, leading to increased intracranial pressure. Manifestations of hydrocephalus in a newborn may include dilated scalp veins, sunset eyes, head enlargement and sutural diastasis due to increased intracranial pressure.

A. Evaluate the firmness of the uterus. B. Administer oxytocin infusion. C. Obtain a type and crossmatch. D. Initiate oxygen therapy by nonrebreather mask.

Correct Answer is A

Explanation

The likely cause of postpartum hypotension is PPH. Assessing the client should be the first step before initiating management.
B. Oxytocin infusion is used to prevent or manage uterine atony and postpartum hemorrhage.

Assessment should be done before administration of oxytocin.

C. Obtaining a type and crossmatch is important if there is established hemorrhage. Should follow assessment
D. Initiating oxygen therapy by nonrebreather mask should be done after established hypoxemia on assessment of vital signs

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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