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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Placing the client in a semi-Fowler’s position for 1 hr after administration is not necessary.
Choice B rationale:
Allowing the medication to reach room temperature prior to administration is not necessary.
Choice C rationale:
Instructing the client to avoid urinary elimination until after administration is not necessary.
Choice D rationale:
Verifying that informed consent is obtained prior to administration is crucial as it ensures the client is aware of the procedure and its potential risks.
Correct Answer is A
Explanation
Choice A rationale:
The nurse should use fingers to exert upward pressure on the presenting part to relieve cord compression, which is the immediate priority in this emergency situation.
Choice B rationale:
Administering a tocolytic medication is not the immediate priority. It may be done later to inhibit uterine contractions.
Choice C rationale:
Applying oxygen to the client is important, but it’s not the first action. The nurse needs to relieve cord compression first.
Choice D rationale:
Wrapping the cord in a sterile towel and moistening with warm sterile normal saline is important, but it’s not the first action. The nurse needs to relieve cord compression first.
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