A nurse is performing a physical examination of a client who is 1 day postpartum. Which of the following findings requires immediate intervention?

Fundal height below the umbilicus

Decreased urge to void

Increased urine output

Displaced fundus from the midline

Answer and Explanation

The Correct Answer is D

A) Fundal height below the umbilicus:

In the immediate postpartum period, the fundus typically descends at a predictable rate. A fundal height below the umbilicus on the first day postpartum is expected. It is not a cause for immediate intervention unless accompanied by other signs of postpartum hemorrhage.

B) Decreased urge to void:

A decreased urge to void is common in the immediate postpartum period due to perineal swelling, episiotomy or lacerations, and the effects of regional anesthesia. However, it is not an immediate concern as long as the client is voiding adequate amounts of urine.

C) Increased urine output:

Increased urine output in the postpartum period is expected due to the diuretic effect of the body eliminating excess fluid retained during pregnancy. It is not a cause for immediate intervention as long as the client is not exhibiting signs of dehydration.

D) Displaced fundus from the midline:

A displaced fundus from the midline is concerning as it may indicate uterine atony, which is the most common cause of postpartum hemorrhage. Immediate intervention is necessary to prevent further complications such as excessive bleeding.

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Correct Answer is ["A","B","D","E"]

Explanation

A) Clean the perineal area from front to back:

This is correct. Instructing the client to clean the perineal area from front to back helps prevent the introduction of fecal bacteria into the vaginal area, reducing the risk of perineal infection.

B) Blot the perineal area dry after cleansing:

This is correct. Instructing the client to blot the perineal area dry after cleansing helps remove excess moisture, which can promote bacterial growth and increase the risk of infection.

D) Perform hand hygiene before and after voiding:

This is correct. Performing hand hygiene before and after voiding is essential to reduce the risk of introducing bacteria from the hands to the perineal area, which can lead to infection.

E) Wash the perineal area using a squeeze bottle of warm water after each voiding:

This is correct. Washing the perineal area with warm water using a squeeze bottle after each voiding helps cleanse the area without causing irritation or trauma, promoting perineal hygiene and reducing the risk of infection.

C) Apply ice packs to the perineal area several times daily:

This is incorrect. While applying ice packs to the perineal area can help reduce swelling and discomfort after vaginal delivery, it is not specifically aimed at reducing perineal infection. Cold therapy is more focused on providing comfort and promoting healing of any perineal trauma rather than preventing infection.

A. Client is Rh negative and the newborn is Rh positive. B. Client is Rh positive and the newborn is Rh negative. C. Client is Rh positive and the newborn is Rh positive. D. Client is Rh negative and the newborn is Rh negative.

Correct Answer is A

Explanation

A) Client is Rh negative and the newborn is Rh positive:

This is the correct response. Rho (D) Immunoglobulin, also known as RhoGAM, is administered to Rh-negative mothers who have given birth to Rh-positive infants. This medication helps prevent the mother's immune system from producing antibodies against Rh-positive blood cells, which could lead to hemolytic disease of the newborn in subsequent pregnancies. Administering RhoGAM in this scenario helps prevent sensitization of the mother's immune system to Rh-positive blood cells.

B) Client is Rh positive and the newborn is Rh negative:

Administering RhoGAM to an Rh-positive mother with an Rh-negative newborn would not be necessary because there is no risk of Rh incompatibility in this situation.

C) Client is Rh positive and the newborn is Rh positive:

Administering RhoGAM to an Rh-positive mother with an Rh-positive newborn would not be necessary because the mother and newborn share the same Rh factor, so there is no risk of Rh incompatibility.

D) Client is Rh negative and the newborn is Rh negative:

Administering RhoGAM to an Rh-negative mother with an Rh-negative newborn would not be necessary because there is no risk of Rh incompatibility in this situation.

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A nurse is performing a physical examination of a client who is 1 day postpartum. Which of the following findings requires immediate intervention?

Nursing Test Bank

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Explanation

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