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 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.

A. "Preterm newborns have a smaller body surface area than normal newborns." B. "Preterm newborns lack adequate temperature control mechanisms." C. "The heat in the incubator rapidly dries the sweat of preterm newborns." D. "The added brown fat layer in a preterm newborn reduces his ability to generate heat.

Correct Answer is B

Explanation

Preterm newborns have immature physiological mechanisms to regulate their body temperature effectively which include subcutaneous fat deposition, fully developed sweat glands, and the ability to shiver. They also have a large surface area increasing heat loss. As a result, preterm

infants are at a higher risk of hypothermia. Incubator care assist in the control of body temperature in the premature neonates.

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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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