A nurse is conducting an assessment on a client who is 4 hours postpartum following a vaginal delivery. Which of the following findings should the nurse prioritize?

Fundus at the level of the umbilicus

Saturated perineal pad in 30 minutes

Approximated edges of episiotomy

Deep tendon reflexes 4+

Answer and Explanation

The Correct Answer is B

Choice A rationale

While the fundus at the level of the umbilicus is a normal finding for a woman who is 4 hours postpartum, it is not the priority in this case. The fundus, which is the top part of the uterus, typically descends at a rate of approximately one fingerbreadth (or one cm) per day, and by the 12th postpartum day, it should no longer be palpable.

Choice B rationale

A saturated perineal pad in 30 minutes is a sign of excessive bleeding, also known as postpartum hemorrhage. This is a serious condition that can lead to shock and other complications if not treated promptly. Therefore, this finding should be prioritized by the nurse.

Choice C rationale

Approximated edges of an episiotomy are a normal finding in the postpartum period. An episiotomy is a surgical incision made in the perineum to enlarge the vaginal opening for delivery. After delivery, the episiotomy is sutured and should heal without complications with proper care. However, this is not the priority finding in this scenario.

Choice D rationale

Deep tendon reflexes 4+ could be a sign of preeclampsia, a pregnancy complication characterized by high blood pressure and signs of damage to another organ system, often the liver and kidneys. However, since the client is already 4 hours postpartum, this is less likely to be the priority.

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Correct Answer is D

Explanation

Choice A rationale

Administering Vitamin K is an important step in newborn care as it helps with blood clotting and prevents a rare but serious bleeding disorder called Vitamin K Deficiency Bleeding.

However, it is not the immediate priority after ensuring a patent airway.

Choice B rationale

Administering eye prophylaxis, typically in the form of antibiotic ointment, is a standard procedure in newborn care to prevent neonatal conjunctivitis. However, this is not the immediate priority after ensuring a patent airway.

Choice C rationale

Placing an identification bracelet on the newborn is crucial for ensuring the baby’s safety and preventing mix-ups. However, this is not the immediate priority after ensuring a patent airway.

Choice D rationale

Drying the skin of the newborn is the priority action after ensuring a patent airway. This is because newborns are wet with amniotic fluid at birth, and they can lose heat quickly through evaporation if not dried immediately. This can lead to hypothermia, which can be dangerous for the newborn.

A. “I will reduce my exercise schedule to 3 days a week.”. B. “I will take my glyburide daily with breakfast.”. C. “I know I am at increased risk to develop type 2 diabetes.”. D. “I should limit my carbohydrates to 50% of caloric intake.”. E. “I should limit my carbohydrates to 50% of caloric intake.”.

Correct Answer is A

Explanation

Choice A rationale

Regular physical activity plays a key role in managing gestational diabetes. The American College of Obstetricians and Gynecologists (ACOG) recommends aiming for 150 minutes of moderate-level exercise each week during pregnancy. Reducing the exercise schedule to 3 days a week may not provide the recommended amount of physical activity needed to manage gestational diabetes effectively.

Choice B rationale

Glyburide is an oral medication that can be used to manage gestational diabetes when diet and exercise are not enough. It is usually taken before breakfast or the first main meal of the day.

Choice C rationale

This statement is correct. Women who have had gestational diabetes have an increased risk of developing type 2 diabetes later in life.

Choice D rationale

This statement is correct. A diet that includes about 40% to 45% carbohydrates is recommended for managing gestational diabetes.

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A nurse is conducting an assessment on a client who is 4 hours postpartum following a vaginal delivery. Which of the following findings should the nurse prioritize?

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a newborn immediately after birth. Once a patent airway has been ensured, what should be the nurse’s priority action?

Correct Answer is D

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

A nurse in a prenatal clinic is teaching a patient who is in her second trimester and has a new diagnosis of gestational diabetes. Which of the following statements by the patient indicates a need for further teaching?

Correct Answer is A

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

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