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

Exhibit 1. Nurses' Notes.

0700:. Exhibit 2. 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.

Vital Signs.

0700:. Temperature 36.2° C (97.2° F). Pulse rate 80/min.

Respiratory rate 16/min.

Blood pressure 136/82 mm Hg. Pulse oximetry 999%. 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.

Peripheral edema 2+ bilateral lower extremities.

Lateral deviation of the uterus.

Large amount of lochia rubra.

Uterine tone soft.

Breasts soft.

Deep tendon reflexes 1+.

Pain rating of 3 on a scale of 0 to 10.

Answer and Explanation

Correct Answer : B,C,D

Choice A rationale:
Peripheral edema is common in the postpartum period and does not require immediate follow-up.
Choice B rationale:
Lateral deviation of the uterus could indicate a full bladder, which requires immediate follow-up.
Choice C rationale:
Large amount of lochia rubra 8 hours postpartum could indicate postpartum hemorrhage, which requires immediate follow-up.
Choice D rationale:
A soft uterine tone could indicate uterine atony, a cause of postpartum hemorrhage, which requires immediate follow-up.
Choice E rationale:
Soft breasts are normal in the immediate postpartum period and do not require immediate follow-up.
Choice F rationale:
Deep tendon reflexes of 1+ are normal and do not require immediate follow-up.
Choice G rationale:
A pain rating of 3 on a scale of 0 to 10 is manageable and does not require immediate follow-up.
Choice H rationale:
Blood pressure of 136/86 mm Hg is slightly elevated but does not require immediate follow-up unless there are other signs of preeclampsia.

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Correct Answer is B

Explanation

Choice A rationale:
A WBC count of 9,000/mm is within the normal range (4,500-11,000/mm).
Choice B rationale:
Uterine tenderness is a common symptom of endometritis.
Choice C rationale:
Scant lochia is not typically associated with endometritis.
Choice D rationale:
A temperature of 37.4° C (99.3° F) is within the normal range.

A. "Yellow exudate will form at the surgical site in 24 hours.”. B. "Notify the provider if the end of your baby's penis appears dark red.”. C. "The Plastibell will be removed 4 hours after the procedure.”. D. "Make sure the newborn's diaper is snug.”.

Correct Answer is A

Explanation

Choice A rationale:
Yellow exudate will form at the surgical site in 24 hours, which is a normal part of the healing process.
Choice B rationale:
A dark red appearance of the penis could indicate a complication such as infection or necrosis, which would require medical attention.
Choice C rationale:
The Plastibell is not removed manually; it falls off naturally within 5 to 8 days.
Choice D rationale:
A snug diaper could cause pressure and discomfort on the surgical site; it’s recommended to fasten the diaper loosely.

The Plastibell circumcision technique is one of the most common methods of newborn circumcision. It involves placing a plastic ring under the foreskin and tying a suture around it to cut off blood flow. The foreskin then falls off naturally with the ring in seven to 10 days.

The correct answer is A. The nurse should include that “yellow exudate will form at the surgical site in 24 hours” as part of the teaching to the parents. This is because the yellow exudate is a normal sign of healing and should not be confused with infection.

The other options are incorrect because:

b. The parents should notify the provider if the end of the baby’s penis appears black, not dark red. This could indicate that the ring is too tight and is cutting off blood supply to the glans.
c. The Plastibell will not be removed 4 hours after the procedure. It will stay on the penis until the foreskin falls off naturally in seven to 10 days.
d. The newborn’s diaper should be loose, not snug. This is to prevent the ring from being dislodged or rubbing against the diaper.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is 6 hr postpartum and has endometritis. Which of the following findings should the nurse expect?

Correct Answer is B

Explanation

A nurse is providing teaching to the parents of a newborn about the Plastibell circumcision technique. Which of the following information should the nurse include?

Correct Answer is A

Explanation

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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 pieces of information should the nurse include?

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