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 D

Explanation

A. Place an identification bracelet:

While important for identification purposes, placing an identification bracelet is not the priority immediately following birth. Ensuring the newborn's physiological stability takes precedence.

B. Administer eye prophylaxis:

Administering eye prophylaxis is an essential newborn care procedure to prevent neonatal conjunctivitis caused by exposure to maternal gonorrhea or chlamydia. However, it is not the priority immediately after ensuring a patent airway.

C. Administer vitamin K:

Administering vitamin K is important for preventing vitamin K deficiency bleeding (VKDB) in newborns. However, it is typically done after drying the skin and other immediate newborn care tasks.

D. Dry the skin:

This is the correct answer. Drying the newborn's skin is the priority after ensuring a patent airway. Drying helps prevent heat loss and stimulates the newborn's breathing and circulation. It is an essential step in newborn care immediately after birth to promote thermal stability and adaptation to extrauterine life.

A. A white patch on a nipple B. Red and painful area in one breast C. Cracked and bleeding nipples D. Swelling in both breasts

Correct Answer is B

Explanation

A) A white patch on a nipple:

A white patch on the nipple may indicate a condition such as a milk bleb or a fungal infection like thrush, but it is not characteristic of mastitis. Mastitis typically presents with localized redness and pain in the affected breast, along with other systemic symptoms such as fever and flu-like symptoms.

B) Red and painful area in one breast:

This finding is indicative of mastitis. Mastitis is an inflammation of the breast tissue, often caused by bacterial infection, which presents with localized redness, warmth, swelling, and pain in one breast. The affected area may also feel tender or hard to the touch.

C) Cracked and bleeding nipples:

Cracked and bleeding nipples are common in breastfeeding mothers, but they are not specific signs of mastitis. However, they can increase the risk of mastitis if bacteria enter the breast tissue through the cracked skin. Proper breastfeeding techniques and nipple care can help prevent nipple damage and reduce the risk of mastitis.

D) Swelling in both breasts:

Swelling in both breasts may occur in the early postpartum period due to engorgement or increased milk production, but it is not a specific sign of mastitis. Mastitis typically presents with localized symptoms in one breast rather than both breasts simultaneously.

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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

Naxlex Comprehensive Predictor Exams

A nurse is caring for a newborn immediately following birth. After assuring a patent airway, what is the priority nursing action?

Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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