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A nurse is assisting with the care of a postpartum client who delivered vaginally 8 hr ago.

Exhibits

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+

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Placing the baby in the bassinet by the bed when using the bathroom does not ensure the baby’s safety. It is important to use the bassinet only as a safe place for the baby, and the baby should not be left unattended or in potentially unsecured areas.
B. Carrying the baby in your arms while walking in the hallway does not prevent abduction and can be risky if you are not vigilant. It is safer to use secure methods for ensuring the baby's safety while moving through the hospital.
C. Ensuring that anyone caring for or transporting your baby is wearing an identification badge is a crucial safety measure. Identification badges help verify that only authorized personnel handle the baby, which helps prevent abductions.
D. If the baby’s identification band slips off, it should be reported immediately to hospital staff rather than being placed in a drawer. The identification band is essential for tracking and ensuring the baby’s safety, so it must be addressed properly to prevent confusion or security issues.

A. Douche after each sexual encounter. B. Avoid urinating at bedtime. C. Refrain from taking bubble baths. D. Eliminate yogurt products from diet. E. Wear cotton-crotch underwear.

Correct Answer is ["C","E"]

Explanation

A. Douching is not recommended as it can disrupt the natural vaginal flora and potentially lead to further infections. Instead, maintaining good hygiene without douching is advised.
B. Urinating before bedtime is actually recommended to help flush out bacteria from the urinary tract. Avoiding urination at bedtime can increase the risk of developing a urinary tract infection.
C. Bubble baths can irritate the vaginal area and increase the risk of a urinary tract infection. Pregnant clients should be advised to avoid bubble baths and use mild, unscented soaps instead.
D. Yogurt products are beneficial because they contain probiotics that can help maintain a healthy balance of bacteria in the vagina and urinary tract. Eliminating yogurt from the diet is not necessary and may be counterproductive.
E. Wearing cotton-crotch underwear helps keep the vaginal area dry and reduces the risk of infections. Cotton allows for better air circulation and absorbs moisture compared to synthetic fabrics.

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A nurse is assisting with the care of a postpartum client who delivered vaginally 8 hr ago. Exhibits Select the 3 findings that require immediate follow-up.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is ["C","E"]

Explanation

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A nurse is assisting with the care of a postpartum client who delivered vaginally 8 hr ago.

Exhibits

Select the 3 findings that require immediate follow-up.