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
Cervical dilation is a positive sign of labor. During labor, the cervix dilates to allow the baby to pass through the birth canal. This is a definitive sign that labor is occurring.
Choice B rationale
Amniotic fluid in the vaginal vault could indicate rupture of membranes, but it does not confirm labor. Labor may or may not be present when the membranes rupture.
Choice C rationale
Pain above the umbilicus is not a typical sign of labor. Labor pain is usually felt in the lower back and lower abdomen.
Choice D rationale
Brownish vaginal discharge could be a sign of “bloody show,” which can occur as labor approaches. However, it does not confirm that labor is occurring.
Correct Answer is C
Explanation
Choice A rationale
While it’s important to report concerns to the primary care provider, this does not directly address the mother’s concern about her newborn’s crossed eyes.
Choice B rationale
Strabismus is a condition where the eyes do not properly align with each other, but it is not the same as the normal crossing of a newborn’s eyes.
Choice C rationale
This is the correct answer. Newborns often lack the muscle control to regulate eye movement, which can cause their eyes to cross.
Choice D rationale
Taking the baby to the nursery for further examination may be necessary if there are other concerns, but it does not directly address the mother’s concern about her newborn’s crossed eyes.
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