A nurse is caring for a client who is 2 days postpartum.
The client is a Gravida 4 Para 3 who had a forceps-assisted birth with epidural anesthesia at 40 weeks of gestation. She had a second degree mediolateral perineal laceration with repair, and the placenta was manually extracted.
The estimated blood loss was 600 mL. Complete the diagram by dragging from the choices below to specify what condition the client is experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client’s progress.
Apply ice packs to the perineal area.
Monitor for signs of postpartum seizures.
Monitor for signs of strained perineum.
Administer prescribed medications.
Correct Answer : A,C
A nurse is caring for a client who is 2 days postpartum.
The client is a Gravida 4 Para 3 who had a forceps-assisted birth with epidural anesthesia at 40 weeks of gestation. She had a second degree mediolateral perineal laceration with repair, and the placenta was manually extracted.
The estimated blood loss was 600 mL. Complete the diagram by dragging from the choices below to specify what condition the client is experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client’s progress.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Assessing the fetal heart rate pattern is the priority nursing action following an amniotomy. This allows the nurse to monitor for signs of fetal distress, which can occur if the umbilical cord becomes compressed or prolapses as a result of the procedure.
Choice B rationale
Observing the color and consistency of the fluid can provide information about the well-being of the fetus, but it is not the priority action following an amniotomy.
Choice C rationale
Assessing the client’s temperature is important to monitor for signs of infection, but it is not the priority action following an amniotomy.
Choice D rationale
Evaluating the client for the presence of chills and increased uterine tenderness using palpation can help identify complications such as infection or uterine rupture, but it is not the priority action following an amniotomy.
Correct Answer is B
Explanation
Choice A rationale: Fundus at umbilicus is expected 4 hours postpartum, indicating normal uterine involution. No abnormal bleeding or uterine atony is implied, so it’s not a priority concern.
Choice B rationale: Deep tendon reflexes 4+ are hyperactive and signal increased neuromuscular irritability, placing the client at high risk for seizures due to preeclampsia. Immediate magnesium sulfate therapy may be required.
Choice C rationale: Saturated pad in 30 minutes suggests heavy lochia but is not yet classified as hemorrhage. Requires monitoring, but seizure risk from preeclampsia is more immediately life-threatening.
Choice D rationale: Approximated episiotomy edges indicate proper healing and no infection or dehiscence. This is a normal finding and does not require urgent intervention.
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