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 D
Explanation
Choice A rationale
Decreasing the rate of IV fluids would not address the issue of late decelerations, which are a sign of fetal hypoxia.
Choice B rationale
Elevating the client’s head would not address the issue of late decelerations.
Choice C rationale
Performing fetal scalp stimulation is used to assess fetal well-being when the tracing is nonreactive, not when late decelerations are present.
Choice D rationale
Administering oxygen via a face mask is the correct answer. This increases maternal oxygen saturation, which can help increase oxygen delivery to the fetus.
Correct Answer is B
Explanation
Choice A rationale
While blood in the stool can be a sign of a problem in older children and adults, it is not uncommon for newborns to pass dark green or black stools (known as meconium) in the first few days after birth. This does not typically indicate a problem.
Choice B rationale
A newborn vomiting eight to ten times per day is a cause for concern. This could indicate a problem such as pyloric stenosis or gastroesophageal reflux disease, both of which require medical attention.
Choice C rationale
Cooling after each breastfeeding is not typically a sign of a problem. Newborns have immature temperature regulation systems, so slight variations in body temperature can occur.
Choice D rationale
Persistent crossing of the eyes in a newborn can be normal up to about 3 months of age. If it continues beyond this point, it may indicate a problem such as strabismus.
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