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 ["B","D","E","F"]
Explanation
Grunting, nasal flaring, and sternal retractions are signs of respiratory distress in a newborn. These findings suggest that the newborn is having difficulty breathing and may require further evaluation and intervention by the provider.
Hematocrit levels may be indicative of polycythemia or other hematological abnormalities, which could impact the newborn's well-being and require further assessment and management. Changes in heart rate may indicate cardiac or circulatory issues in the newborn, which warrant further evaluation by the provider.
Respiratory distress in the neonatal period can also occur due to neonatal sepsis and hence, WBC count is important.
Temperature is important to assess in newborns, but it is not explicitly indicated as abnormal in the scenario provided. Newborn's serum glucose level is essential, it is not mentioned in the scenario and is not typically a priority in this context unless there are specific risk factors or symptoms of hypoglycemia.
Correct Answer is ["A","C","D"]
Explanation
A.The client should limit carbohydrate intake to reduce the risk of gestational diabetes and its complications both in the mother and the fetus.
Glucose monitoring should be done 4 times daily.
C. Metformin is commonly prescribed to manage glucose levels in pregnant individuals with GDM.
D. The client's history of macrosomic newborns and family history of type 1 diabetes mellitus indicate an increased risk for complications such as fetal macrosomia and fetal distress. Nonstress tests are used to assess fetal well-being by monitoring fetal heart rate patterns.
E. With a BMI of 32 and a history of macrosomic newborns, the client is at an increased risk for developing gestational diabetes mellitus (GDM). Regular exercise is important in managing blood glucose levels and reducing the risk of GDM.
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