A nurse is assisting with the care of a postpartum client who delivered vaginally 8 hr ago.
Select the 3 findings that require immediate follow-up.
Blood pressure 136/86 mm Hg
Peripheral edema 2+ bilateral lower extremities
Lateral deviation of the uterus
Breasts soft
Pain rating of 3 on a scale of 0 to 10
Uterine tone soft
Large amount of lochia rubra
Deep tendon reflexes 1+
Correct Answer : C,F,G
A. Blood pressure 136/86 mm Hg
- The blood pressure reading is slightly elevated but not critically high. Postpartum hypertension can be a concern, but this level does not indicate an immediate risk.
- This reading is consistent with the earlier measurement, suggesting stability.
- Immediate follow-up is not required unless there is a significant increase or additional symptoms are present.
B. Peripheral edema 2+ bilateral lower extremities
- Edema is common in the postpartum period due to fluid shifts and should resolve naturally.
- The consistent 2+ rating indicates no acute change.
- Monitoring is appropriate, but it does not require immediate follow-up unless it worsens or is accompanied by other symptoms.
C. Lateral deviation of the uterus
- A laterally deviated uterus can indicate a displaced uterus, possibly due to a full bladder or other reasons, which requires prompt attention.
- The deviation from the firm, midline position noted earlier could suggest an underlying issue that needs immediate investigation.
- This finding could lead to complications if not addressed promptly.
D. Breasts soft
- Soft breasts are normal postpartum when milk has not yet come in or if the client is not breastfeeding.
- There is no change from the earlier assessment.
- This does not require immediate follow-up as it is a normal finding.
E. Pain rating of 3 on a scale of 0 to 10
- A pain rating of 3 is mild and manageable, especially considering it was 2 earlier.
- This slight increase in pain is expected and can be monitored with routine care.
- It does not necessitate immediate follow-up unless there is a sudden and significant increase in pain.
F. Uterine tone soft
- A soft uterine tone postpartum can indicate uterine atony, which can lead to hemorrhage.
- The change from a previously firm uterus to a soft one is concerning.
- Immediate follow-up is necessary to prevent potential complications such as postpartum hemorrhage.
G. Large amount of lochia rubra
- A large amount of lochia rubra can be a sign of excessive bleeding.
- The increase from a moderate amount earlier to a large amount could indicate a hemorrhagic complication.
- This finding requires immediate follow-up to assess for postpartum hemorrhage.
H. Deep tendon reflexes 1+
- A deep tendon reflex of 1+ is considered within normal limits.
- There has been no change from the earlier assessment.
- This finding does not require immediate follow-up as it is a normal finding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"C"},"C":{"answers":"C"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"B"},"G":{"answers":"A"}}
Explanation
- Encourage frequent ambulation: Anticipated. Ambulation can help progress labor, unless contraindicated by the healthcare provider.
- Prepare the client for catheterization: Non-essential. There is no current indication for catheterization as the client is voiding adequately and not in active labor.
- Ensure the client maintains a supine position while in bed: Contraindicated. The supine position can cause supine hypotensive syndrome in pregnant clients. A side-lying position is preferred to optimize blood flow.
- Check FHR every 30 min: Anticipated. Regular monitoring of FHR is important to assess fetal well-being during labor.
- Perform a Nitrazine test: Anticipated. Since the client reports fluid leakage, a Nitrazine test can help confirm if the membranes have ruptured.
- Check client's temperature every hour: Non-essential. The client's temperature is stable, and hourly checks are not indicated unless there are signs of infection or the membrane has been ruptured for an extended period.
- Obtain CBC blood sample: Anticipated. A CBC can help identify any underlying issues such as anemia or infection that could affect labor and delivery.
Correct Answer is A
Explanation
A. The Papanicolaou (Pap) test is used to detect abnormal cells on the cervix that could indicate cervical cancer or precancerous changes. It is a screening tool for early detection of cervical cancer and helps prevent the disease from developing.
B. The Pap test does not detect endometriosis. Endometriosis is a condition where tissue similar to the lining of the uterus grows outside the uterus, and it requires different diagnostic methods such as laparoscopy.
C. The Pap test does not allow for the removal of uterine fibroids. Uterine fibroids are diagnosed and managed through other procedures, such as hysteroscopy or surgical removal.
D. The Pap test does not determine ovulation status. Ovulation status is assessed through methods like ovulation predictor kits or monitoring basal body temperature.
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