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 B
Explanation
Choice A rationale
Transient occipital cyanosis is not a clinical finding that should be reported to the provider. It is a normal finding in newborns due to immature circulation and should resolve on its own.
Choice B rationale
Single palmar creases, also known as simian lines, can be a sign of certain genetic conditions, such as Down syndrome. Therefore, this finding should be reported to the provider.
Choice C rationale
Subconjunctival hemorrhage, or a red spot in the white of the eye, is a common and harmless condition in newborns. It does not require treatment and will disappear as the blood is absorbed.
Choice D rationale
Dystocia, or difficult labor, is not a clinical finding in a newborn. It refers to a situation during childbirth where there is slow or difficult labor or delivery.
Correct Answer is B
Explanation
Choice A rationale
Progressive sacral discomfort during contractions is a normal part of labor and does not necessarily require reassessment.
Choice B rationale
An urge to have a bowel movement during contractions could indicate that the baby’s head is descending into the birth canal. This could signal that the labor is progressing more quickly than expected, and the nurse should reassess the client.
Choice C rationale
Intense contractions lasting 45 to 60 seconds are a normal part of active labor and do not necessarily require reassessment.
Choice D rationale
A sense of excitement and warm, flushed skin are normal emotional and physiological responses to labor and do not necessarily require reassessment.
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