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 ["A","B","D","F","G"]

Explanation

A. Monitor blood pressure: The client’s blood pressure readings (148/94 mm Hg and 156/96 mm Hg) indicate hypertension in pregnancy, which requires frequent monitoring to detect worsening preeclampsia and prevent complications such as stroke or placental abruption.

B. Check urinary output: Elevated BUN and creatinine, along with proteinuria, indicate possible renal involvement from preeclampsia. Monitoring urinary output helps assess kidney function and detect oliguria, a critical warning sign.

C. Initiate contact precautions: There is no evidence of an infectious condition requiring contact precautions. Standard precautions are sufficient for this client.

D. Monitor deep tendon reflexes: Hyperreflexia (DTR 3+) is a hallmark sign of preeclampsia and indicates increased seizure risk. Ongoing monitoring is essential for early recognition of worsening neurological status.

E. Assist with preparing the client for amniocentesis: Amniocentesis is not indicated based on the current clinical findings. Immediate priorities involve maternal stabilization and fetal monitoring, not diagnostic invasive procedures.

F. Encourage bedrest: Bedrest can help reduce blood pressure and improve uteroplacental perfusion in clients with preeclampsia. Positioning the client on her left side optimizes blood flow to the fetus and kidneys.

G. Assist with application of internal fetal monitor: The client has minimal variability on the external fetal monitor, suggesting potential fetal compromise. Internal fetal monitoring may be indicated for more accurate assessment of fetal status, so assisting with its application is appropriate.

A. Placement of a central venous catheter B. insertion of a nasogastric tube C. Administration of an iron injection using Z-track technique D. Irrigation of a wound with antibiotic solution

Correct Answer is A

Explanation

A. Placement of a central venous catheter: Inserting a central venous catheter is an invasive procedure with significant risks, including infection, bleeding, and pneumothorax. Informed consent is required to ensure the client understands the procedure, its risks, benefits, and alternatives before it is performed.

B. Insertion of a nasogastric tube: NG tube insertion is a common, low-risk procedure typically performed by nurses as part of routine care. It generally does not require formal informed consent, though verbal explanation and client cooperation are important.

C. Administration of an iron injection using Z-track technique: Administering an intramuscular injection is considered a routine nursing procedure. While clients should be informed about the medication and technique, formal written consent is not typically required.

D. Irrigation of a wound with antibiotic solution: Wound irrigation is a standard nursing intervention performed as part of routine care. It does not require formal informed consent, although the client should be informed about the procedure and purpose.

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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?

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