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 []
Explanation
- Potential Condition: Hypoglycemia
- Rationale: The jitteriness and weak cry can be signs of hypoglycemia, which is common in newborns, especially those with higher birth weights or whose mothers have diabetes or, in this case, a history of substance use during pregnancy.
Actions to Take:
1. Reinforce with the parent to feed the newborn: Feeding can help to stabilize the newborn's blood sugar levels.
2. Anticipate a prescription to obtain a capillary blood sample: This will confirm the diagnosis by measuring the newborn's blood glucose levels.
Parameters to Monitor:
1. Temperature: To ensure the newborn maintains a normal body temperature, as hypothermia can be associated with hypoglycemia.
2. Respiratory status: To monitor for any changes that could indicate worsening of the condition or other complications.
Correct Answer is C
Explanation
A. A Mongolian spot is a benign, pigmented skin mark common in newborns, particularly those with darker skin. It is not related to rubella exposure during pregnancy.
B. Jaundice in the newborn can be a common finding and is not specifically related to maternal rubella exposure. Jaundice often resolves with time or may require treatment, but it is not a direct consequence of rubella.
C. Deafness is a known congenital defect associated with rubella syndrome. Infants exposed to rubella during pregnancy are at risk for serious outcomes, including hearing impairments.
D. Transient strabismus is a common condition in newborns and is not specifically associated with maternal rubella exposure. It typically resolves as the baby grows.
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