A nurse is collecting data from a client who is 20 hr postpartum following a vaginal delivery. Which of the following findings should the nurse expect?

Positive Homans' sign

Full, firm breasts

Firm fundus at midline

Lochia serosa

Answer and Explanation

The Correct Answer is C

A.   Homans' sign is a test for deep vein thrombosis and is not a normal postpartum finding.
B.   Full, firm breasts typically occur a few days after delivery when milk production begins, not at 20 hours postpartum.
C.   A firm fundus at the midline is an expected finding in the immediate postpartum period, indicating that the uterus is contracting and involuting properly.
D.   Lochia serosa (pinkish-brown discharge) is a normal finding around 3 to 10 days postpartum, but it is not typically present at 20 hours postpartum.

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Correct Answer is A

Explanation

A. At 12 weeks of gestation, the nurse should expect to find the fetal heart tones in the suprapubic area. This is where the uterus is located at this early stage of pregnancy.
B. This is not the correct location for auscultating fetal heart tones at 12 weeks of gestation. The umbilical area is not the typical location for auscultating fetal heart tones at this stage.
C. This is not the correct location for auscultating fetal heart tones at 12 weeks of gestation. At this stage, the nurse should expect to find fetal heart tones in the suprapubic region.
D. This is not the correct location for auscultating fetal heart tones at 12 weeks of gestation. The liver is typically not involved in auscultating fetal heart tones at this stage.

A. Hyporeflexia B. Tachypnea C. Polyuria D. Agitation

Correct Answer is A

Explanation

A. Hyporeflexia is a significant adverse effect of magnesium sulfate therapy and can indicate magnesium toxicity. It is essential for the nurse to monitor deep tendon reflexes as part of the assessment when a client is receiving this medication. A decrease in reflexes may warrant immediate intervention and reporting to the provider.
B. Tachypnea is not a common adverse effect of magnesium sulfate; however, if it occurs, it may indicate respiratory distress, which should be assessed further.
C. Polyuria is not a typical adverse effect of magnesium sulfate. In fact, magnesium can lead to decreased urine output in some cases, especially with toxicity.
D. Agitation is also not a typical adverse effect of magnesium sulfate. Clients receiving magnesium sulfate may exhibit sedation rather than agitation.

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A nurse is collecting data from a client who is 20 hr postpartum following a vaginal delivery. Which of the following findings should the nurse expect?

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Naxlex Comprehensive Predictor Exams

A nurse is auscultating fetal heart tones with a Doppler device for a client who is at 12 weeks of gestation. Where should the nurse expect to auscultate the fetal heart tones?

Correct Answer is A

Explanation

A nurse in an antepartum unit is assisting with the care of a client who has preeclampsia and is receiving IV magnesium sulfate therapy. For which of the following adverse effects should the nurse monitor and report to the provider?

Correct Answer is A

Explanation

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