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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.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A rationale:
Replacing the infant’s identification band after his name has been recorded is not a recommended practice for newborn identification.
Choice B rationale:
Checking the newborn’s identification using the crib card is not a recommended practice for newborn identification.
Choice C rationale:
Obtaining an imprint of the infant’s feet prior to taking him to the nursery is a reliable method of identification of the newborn.
Choice D rationale:
Requiring visitors to wear an identification band is not a recommended practice for newborn identification.

A. Breast tenderness. B. Persistent headaches. C. Vaginal itching. D. Painful intercourse.

Correct Answer is B

Explanation

Choice A rationale:
Breast tenderness is a common side effect of oral contraceptives and does not need immediate medical attention.
Choice B rationale:
Persistent headaches can be a sign of a serious side effect such as a stroke or blood clot and should be reported immediately.
Choice C rationale:
Vaginal itching could be a sign of a yeast infection, but it’s not typically associated with oral contraceptives.
Choice D rationale:
Painful intercourse could be due to various reasons, but it’s not a common side effect of oral contraceptives.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse manager is revising a maternal unit policy to ensure proper identification of newborns. Which of the following should the nurse include in the policy?

Correct Answer is C

Explanation

A nurse is caring for a client who is taking an oral contraceptive. The nurse should instruct the client to report which of the following findings to the provider immediately?

Correct Answer is B

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?

A nurse is caring for a postpartum client who recently had an indwelling urinary catheter removed. Which of the following findings indicates that the client is able to void effectively?

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.).

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 administering a 500 mL bolus of lactated Ringer's for a client who is in labor and has a prescription for spinal anesthesia. Which of the following findings indicates that the IV bolus was effective?

A nurse is planning care for a client who is 1 hr postpartum and has preeclampsia without severe features. Which of the following actions should the nurse plan to take?

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 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?