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  1. A nurse is assessing a postpartum client who delivered vaginally 8 hr ago.

Exhibit 1

Nurses' Notes

0700:

Breasts soft, nipples intact. Uterus palpated firm, midline, and at level of umbilicus. Moderate amount of lochia rubra. Episiotomy site well approximated with mild edema and ecchymosis. Client reports pain as 2 on a scale of 0 to 10. Able to void spontaneously; no bladder distention. Deep tendon reflexes 1+. Peripheral edema 2+ in bilateral lower extremities.

1100:

Breasts soft, nipples intact. Uterus palpated soft with lateral deviation and 1 cm above the umbilicus. Large amount of lochia rubra. Episiotomy site well approximated with mild edema and ecchymosis. Client reports pain as 3 on a scale of 0 to 10. Deep tendon reflexes 1+ Peripheral edema 2+ in bilateral lower extremities.

Exhibit 2

0700:

Temperature 36.2" C (97.2" F) Pulse rate 80/min

Respiratory rate 16/min

Blood pressure 136/82 mm Hg

Pulse oximetry 99%

1100:

Temperature 37.2° C (99.0° F)

Pulse rate 85/min

Respiratory rate 18/min

Blood pressure 136/86 mm Hg

Pulse oximetry 100%

Select the 3 findings that require immediate follow-up.

A.

Uterine tone soft

B.

Blood pressure 136/86 mm Hg

C.

Peripheral edema 2+ bilateral lower extremities

D.

Large amount of lochia rubra

E.

Pain rating of 3 on a scale of 0 to 10

F.

Breasts soft

G.

Lateral deviation of the uterus

Answer and Explanation

Correct Answer : A,D,G

A. Uterine tone soft: A soft uterus can indicate inadequate uterine contraction, which may increase the risk of postpartum hemorrhage. The uterus should be firm and well-contracted after delivery.

B. Blood pressure 136/86 mm Hg:
A blood pressure of 136/86 mm Hg is within the normal range for a postpartum client. While changes in blood pressure should be monitored, this reading alone does not indicate an urgent need for follow-up.

C. Peripheral edema 2+ bilateral lower extremities:
Peripheral edema is a common finding in the postpartum period and is often attributed to fluid shifts and hormonal changes. While it should be monitored, it does not typically require immediate follow-up unless it is severe or associated with other symptoms.

D. Large amount of lochia rubra: While lochia rubra is normal in the first few days postpartum, a large amount could indicate potential bleeding issues or complications if it increases significantly.

E. Pain rating of 3 on a scale of 0 to 10:
A pain rating of 3 on a scale of 0 to 10 is relatively mild and may be expected after a vaginal delivery, especially if the client has undergone an episiotomy. It should be addressed but does not require immediate follow-up unless it worsens or is associated with other concerning symptoms.

F. Breasts soft:
Soft breasts are expected in the early postpartum period, particularly if the client is not breastfeeding or if breastfeeding has not yet been established. However, breastfeeding assessment and support should be provided as part of routine postpartum care.

G. Lateral deviation of the uterus:The uterus should be midline and firm. A lateral deviation could suggest a full bladder or other complications that need to be addressed to prevent further issues such as postpartum hemorrhage.

H. Deep tendon reflexes 1+:
Deep tendon reflexes of 1+ are within the normal range and do not typically require immediate follow-up unless they are absent or hyperactive, which may indicate neurological issues.


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Related Questions

Correct Answer is ["A","D","G"]

Explanation

A. Uterine tone soft:A soft uterus can indicate inadequate uterine contraction, which may increase the risk of postpartum hemorrhage. The uterus should be firm and well-contracted after delivery.

B. Blood pressure 136/86 mm Hg:
A blood pressure of 136/86 mm Hg is within the normal range for a postpartum client. While changes in blood pressure should be monitored, this reading alone does not indicate an urgent need for follow-up.

C. Peripheral edema 2+ bilateral lower extremities:
Peripheral edema is a common finding in the postpartum period and is often attributed to fluid shifts and hormonal changes. While it should be monitored, it does not typically require immediate follow-up unless it is severe or associated with other symptoms.

D. Large amount of lochia rubra: While lochia rubra is normal in the first few days postpartum, a large amount could indicate potential bleeding issues or complications if it increases significantly.

E. Pain rating of 3 on a scale of 0 to 10:
A pain rating of 3 on a scale of 0 to 10 is relatively mild and may be expected after a vaginal delivery, especially if the client has undergone an episiotomy. It should be addressed but does not require immediate follow-up unless it worsens or is associated with other concerning symptoms.

F. Breasts soft:
Soft breasts are expected in the early postpartum period, particularly if the client is not breastfeeding or if breastfeeding has not yet been established. However, breastfeeding assessment and support should be provided as part of routine postpartum care.

G. Lateral deviation of the uterus:The uterus should be midline and firm. A lateral deviation could suggest a full bladder or other complications that need to be addressed to prevent further issues such as postpartum hemorrhage.

H. Deep tendon reflexes 1+:
Deep tendon reflexes of 1+ are within the normal range and do not typically require immediate follow-up unless they are absent or hyperactive, which may indicate neurological issues.

Correct Answer is B

Explanation

A. Heart rate 90/min:

A heart rate of 90 beats per minute is within the normal range for a postpartum client. While tachycardia (an elevated heart rate) can be a sign of hemorrhage, a heart rate of 90/min alone is not necessarily indicative of hemorrhage.

B. Blood pressure 88/40 mm Hg:

A blood pressure of 88/40 mm Hg is low and may indicate hypotension, which can be a sign of hemorrhage. Hypotension, especially when accompanied by other signs such as tachycardia, pallor, or altered mental status, can indicate significant blood loss.

C. Urinary output 40 mL/hr:

A urinary output of 40 mL/hr is low and may indicate decreased perfusion, which can be a sign of hemorrhage. Postpartum hemorrhage can lead to decreased blood volume, resulting in decreased organ perfusion and urine output.

D. Moderate rubra lochia:

Lochia rubra, which is red-tinged vaginal discharge occurring in the first few days after childbirth, is normal postpartum. However, the presence of moderate rubra lochia alone is not a definitive sign of hemorrhage. It's essential to assess the amount, color, and consistency of lochia along with other clinical signs and symptoms.

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