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 B
Explanation
Choice A rationale:
Asking if the partner is pressuring the client to have sex is important, but it’s not the most relevant question when a client requests birth control.
Choice B rationale:
Asking what the client knows about contraception is the most relevant question. It allows the nurse to assess the client’s knowledge and provide appropriate education.
Choice C rationale:
Asking if the client is sure their partner loves them is not relevant to the client’s request for birth control.
Choice D rationale:
Asking why the client is requesting birth control is important, but it’s not as relevant as assessing the client’s knowledge about contraception.
Correct Answer is A
Explanation
Choice A rationale:
Urinating 30 mL/hr is correct. This is within the normal urinary output range of 30 to 60 mL/hr, indicating effective voiding.
Choice B rationale:
Not feeling the urge to urinate is incorrect. This could indicate urinary retention, not effective voiding.
Choice C rationale:
A uterine fundus 2 cm above the umbilicus is incorrect. This is unrelated to the client’s ability to void effectively.
Choice D rationale:
A distended bladder upon palpation is incorrect. This could suggest urinary retention, not effective voiding.
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