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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.

Uterine tone soft

Blood pressure 136/86 mm Hg

Peripheral edema 2+ bilateral lower extremities

Large amount of lochia rubra

Pain rating of 3 on a scale of 0 to 10

Breasts soft

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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Correct Answer is A

Explanation

A. "Hypnosis can be beneficial if you practiced it during the prenatal period":

This statement is accurate. Hypnosis techniques for pain management during labor can be more effective if the client has practiced and familiarized themselves with the techniques during the prenatal period. Regular practice can help the client achieve a deeper state of relaxation and better utilize hypnosis for pain control during labor.

B. "Synchronized breathing will be required during hypnosis":

While synchronized breathing techniques can be part of hypnosis practice, it is not necessarily a requirement for hypnosis to be effective for pain management during labor. Different hypnosis techniques may focus on various aspects such as visualization, deep relaxation, or suggestion to manage pain.

C. "Focusing on controlling body functions will be helpful during hypnosis":

While focusing on controlling body functions, such as breathing or muscle tension, can be part of hypnosis techniques, it is not the only focus. Hypnosis for pain management during labor often involves guiding the mind to a state of deep relaxation and altering perceptions of pain rather than directly controlling body functions.

A. Move the client onto their hands and knees. B. Press firmly on the client's suprapubic area. C. Apply pressure to the client's fundus. D. Assist the client in pulling their knees toward their abdomen.

Correct Answer is D

Explanation

A. Move the client onto their hands and knees.

This action refers to the Gaskin maneuver, which involves changing the maternal position to help alleviate shoulder dystocia during childbirth. By positioning the client on their hands and knees, gravity assists in changing the orientation of the pelvis, potentially allowing more space for the baby to be delivered. While the Gaskin maneuver can be effective in some cases of shoulder dystocia, it is not the McRoberts maneuver.

B. Press firmly on the client's suprapubic area.

This action describes the Rubin maneuver, another technique used to address shoulder dystocia. With the Rubin maneuver, pressure is applied to the anterior shoulder of the fetus, aiming to rotate it into an oblique diameter, which may help dislodge the shoulder from behind the symphysis pubis. While the Rubin maneuver can be helpful in certain cases of shoulder dystocia, it is not the McRoberts maneuver.

C. Apply pressure to the client's fundus.

Applying pressure to the client's fundus is not part of the McRoberts maneuver. In fact, this action is not recommended for managing shoulder dystocia as it could potentially worsen the situation by causing further impaction of the baby's shoulder against the mother's pubic bone.

D. Assist the client in pulling their knees toward their abdomen.

This is the correct action corresponding to the McRoberts maneuver. During the McRoberts maneuver, the nurse assists the client in flexing their hips sharply toward their abdomen. This action helps to widen the pelvic outlet and may facilitate the release of the impacted shoulder, allowing for easier delivery of the baby. The McRoberts maneuver is one of the primary maneuvers used to manage shoulder dystocia during childbirth.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse on a labor and delivery unit is providing teaching to a client who plans to use hypnosis to control labor pain. Which of the following Information should the nurse Include?

Correct Answer is A

Explanation

A nurse is caring for a client who is in the second stage of labor and is experiencing a shoulder dystocia. The provider instructs the nurse to perform the McRoberts maneuver. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is planning care for a client who is 12 hr postpartum and has a third-degree perineal laceration. Which of the following interventions should the nurse include in the plan?

A nurse is caring for a client who is in labor. The nurse observes late decelerations of the fetal heart rate on the external fetal monitor. After placing the client in a side-lying position, which of the following actions should the nurse take?

A nurse is caring for a client who is postpartum and just delivered a newborn who weighs 4.5 kg (10 lb). Which of the following manifestations should the nurse recognize as a potential sign of hemorrhage?

A nurse is providing teaching to a postpartum client who has a prescription for a rubella immunization. Which of the following client statements Indicates understanding of the teaching?

A nurse is assessing the results of a nonstress test for an antepartal client at 35 weeks of gestation. Which of the following findings should indicate to the nurse the need for further diagnostic testing?

A nurse is assessing a client who is 1 hr postpartum. Which of the following findings should the nurse report to the provider?