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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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Naxlex Comprehensive Predictor Exams

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Correct Answer is ["B","D","E"]

Explanation

Choice A rationale:
Abdominal distention is not typically a sign of hypoglycemia in a newborn. It could be related to other factors such as feeding issues or gastrointestinal problems.
Choice B rationale:
Jitteriness can be a sign of hypoglycemia in a newborn as low blood sugar can cause nervous system hyperactivity.
Choice C rationale:
Acrocyanosis, or bluish discoloration of the hands and feet, is common in newborns and is not typically a sign of hypoglycemia.
Choice D rationale:
Hypotonia, or decreased muscle tone, can be a sign of hypoglycemia in a newborn as low blood sugar can affect muscle function.
Choice E rationale:
Temperature instability can be a sign of hypoglycemia in a newborn as low blood sugar can affect the body’s ability to regulate temperature.

A. The client reports a feeling of vaginal fullness. B. The client's fundus is firm and midline. C. The client saturates a perineal pad in 1 hr. D. The client's umbilical cord lengthens.

Correct Answer is B

Explanation

Choice A rationale:
A feeling of vaginal fullness is not a therapeutic effect of oxytocin. It could indicate a vaginal hematoma or retained placental fragments.
Choice B rationale:
The client’s fundus is firm and midline. This is the expected therapeutic effect of oxytocin. It stimulates uterine contractions to prevent postpartum hemorrhage.
Choice C rationale:
Saturating a perineal pad in 1 hr could indicate postpartum hemorrhage, which is not a therapeutic effect of oxytocin.
Choice D rationale:
The client’s umbilical cord lengthening is not related to oxytocin administration. It could indicate placental separation.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a newborn who is 2 hr old. Which of the following findings is an indication of hypoglycemia? (Select all that apply.).

Correct Answer is ["B","D","E"]

Explanation

A nurse is caring for a client who is in the third stage of labor and has a prescription for IV oxytocin administration following expulsion of the placenta. Which of the following clinical manifestations should the nurse expect as a therapeutic effect of the medication?

Correct Answer is B

Explanation

A nurse is providing teaching about the expected effects of magnesium sulfate to a client who is at 28 weeks of gestation and has preeclampsia. Which of the following responses by the nurse is appropriate?

A nurse is caring for a newborn who was born at 39 weeks of gestation and is 36 hours old. Exhibits Which of the following findings should the nurse report to the provider? Select all that apply.

A nurse is caring for a client who delivered by cesarean birth 6 hr ago. The nurse notes a steady trickle of vaginal bleeding that does not stop with fundal massage. Which of the following actions should the nurse take?

A nurse is caring for a client following a vaginal delivery of a term fetal demise. Which of the following statements should the nurse make?

A nurse is caring for a client who is postpartum and has a perineal laceration. Which of the following findings places the client at risk for delayed wound healing?

A nurse is caring for a client who is experiencing an amniotic fluid embolism during labor. Which of the following actions should the nurse take?

A nurse is reviewing the history of a client who is pregnant. Which of the following clinical data indicates the client is at risk for preterm delivery?

A nurse is providing instructions to a client who has chosen a diaphragm for birth control. Which of the following instructions should the nurse include?