A nurse is assisting with the care of a client who is 24 hours following a vaginal birth. Which of the following findings should the nurse report to the RN?

Fundus is located 2 cm (0.4 in) below the level of the umbilicus

Scant lochia rubra on the perineal pad

Non-pitting bilateral peripheral edema

Oral temperature of 38.8° C (101)

Answer and Explanation

The Correct Answer is D

A. Fundus is located 2 cm (0.4 in) below the level of the umbilicus: A fundus slightly below the umbilicus 24 hours postpartum is expected as the uterus involutes. This is a normal finding and does not require immediate reporting unless accompanied by excessive bleeding or other concerning signs.

B. Scant lochia rubra on the perineal pad: Scant lochia rubra is typical within the first 24 hours postpartum, indicating normal uterine shedding. It is expected and does not indicate a complication in the absence of heavy bleeding or foul odor.

C. Non-pitting bilateral peripheral edema: Mild non-pitting edema in the lower extremities can occur postpartum due to fluid shifts and is usually self-limiting. It is not typically emergent unless accompanied by severe swelling, pain, or signs of deep vein thrombosis.

D. Oral temperature of 38.8° C (101° F): An elevated temperature above 38° C 24 hours postpartum may indicate infection, such as endometritis or urinary tract infection. This finding requires immediate reporting to the RN for further assessment and intervention.

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Correct Answer is C

Explanation

A. A toddler who has atopic dermatitis: Atopic dermatitis is a common chronic skin condition and does not increase the risk of child maltreatment. While it may require ongoing care, it is not associated with higher rates of abuse or neglect.

B. An only child: Being an only child is not a recognized risk factor for child maltreatment. Maltreatment risk is more closely related to caregiver stress, child vulnerability, and family dynamics rather than sibling status.

C. A school-age child who has cerebral palsy: Children with physical or developmental disabilities are at increased risk for maltreatment due to caregiver stress, dependency, and communication barriers. These children may be less able to protect themselves or report abuse, making them more vulnerable.

D. A child who was conceived by in vitro fertilization: Conception through assisted reproductive technology does not increase the risk of child maltreatment. These children are often highly desired and planned, which does not align with known risk factors for abuse or neglect.

A. "You should give your child captopril 200 mg PO daily." B. "Your child should have surgery in 7 to 10 days to remove the tumor” C. "Your child will not require further treatment after removal of the tumor" D. "You should not palpate your child's abdomen prior to surgery.”

Correct Answer is D

Explanation

A. "You should give your child captopril 200 mg PO daily.": Captopril is an antihypertensive and is not routinely prescribed for Wilms’ tumor unless the child has hypertension. It is not part of standard preoperative management and should not be included in general parent teaching for tumor care.

B. "Your child should have surgery in 7 to 10 days to remove the tumor.": The timing of surgery is individualized based on the child’s condition, staging, and preoperative assessments. Providing a specific timeframe may be inaccurate and cause unnecessary confusion or anxiety.

C. "Your child will not require further treatment after removal of the tumor.": Wilms’ tumor often requires multimodal therapy, including chemotherapy and sometimes radiation, depending on tumor stage and histology. Parents should be aware that surgery alone may not be sufficient for complete treatment.

D. "You should not palpate your child's abdomen prior to surgery.": Palpating the abdomen can risk rupturing the tumor and spreading cancer cells, which could worsen prognosis. Parents should be instructed to avoid abdominal palpation and handle the child gently until surgical removal of the tumor.

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A nurse is assisting with the care of a client who is 24 hours following a vaginal birth. Which of the following findings should the nurse report to the RN?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is discussing risk factors for child maltreatment with a newly licensed nurse. Which of the following examples should the nurse include?

Correct Answer is C

Explanation

A nurse is reinforcing teaching with the parents of a child who has a new diagnosis of Wilms' tumor. Which of the following information should the nurse include in the teaching?

Correct Answer is D

Explanation

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