A nurse is caring for a 32-year-old female client in the postpartum unit who had a cesarean birth due to preeclampsia. The client has been prescribed misoprostol.
Exhibits
The nurse is assessing the client 1 hour later. How should the nurse interpret the findings?
For each finding, click to specify whether the finding is unrelated to the diagnosis, an indication of potential improvement, or an indication of potential worsening condition.
Fundus 2 cm above umbilicus
Blood pressure 90/60 mm Hg
Heart rate 110/min
Continued heavy vaginal bleeding
Client reports feeling dizzy
Cloudy urine
The Correct Answer is {"A":{"answers":"C"},"B":{"answers":"B"},"C":{"answers":"C"},"D":{"answers":"C"},"E":{"answers":"C"},"F":{"answers":"A"}}
• Fundus 2 cm above umbilicus: This could be a sign of potential worsening condition as it might indicate uterine atony, a condition in which the uterus fails to contract after the delivery, leading to continuous bleeding.
• Blood pressure 90/60 mm Hg: This could be an indication of potential improvement as it is within the normal range, and lower than the previous reading which was elevated due to preeclampsia.
• Heart rate 110/min: This could be a sign of potential worsening condition as it is slightly elevated, which could be a response to blood loss.
• Continued heavy vaginal bleeding: This could be a sign of potential worsening condition as it might indicate postpartum hemorrhage.
• Client reports feeling dizzy: This could be a sign of potential worsening condition as it might be due to blood loss leading to decreased perfusion to the brain.
• Cloudy urine: This is unrelated to the diagnosis. It could be due to dehydration or a urinary tract infection, but it’s not directly related to preeclampsia or postpartum hemorrhage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Leukorrhea, or vaginal discharge, is a common occurrence in pregnancy due to hormonal changes, but it is not a specific sign of abruptio placentae.
Choice B rationale
Hypertension can be a risk factor for abruptio placentae, but it is not a direct sign of the condition.
Choice C rationale
Uterine tenderness is a common symptom of abruptio placentae. This condition, which involves the premature separation of the placenta from the uterus, can cause the uterus to become irritable and sensitive to touch.
Choice D rationale
Fetal tachycardia can be a sign of fetal distress, which could be a result of various complications in pregnancy, including abruptio placentae. However, it is not a specific sign of abruptio placentae.
Correct Answer is C
Explanation
Correct answer: C. Poor feeding
Newborns exposed to methadone in utero are at risk for neonatal abstinence syndrome (NAS), which can manifest with:
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Poor feeding due to uncoordinated suck and swallow reflexes, irritability, and gastrointestinal symptoms.
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High-pitched cry, not weak—so option B is incorrect.
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Exaggerated Moro reflex, not absent—so option A is incorrect.
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Tachypnea (rapid breathing), often >60/min—so a respiratory rate of 30/min is abnormally low and not expected in this context, making option D incorrect.
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