What physical assessment data should the nurse consider a normal finding for a primigravida client who is 12 hours postpartum?
Unilateral lower leg pain.
Soft, spongy fundus.
Pulse rate of 56 beats/minute.
Saturating two perineal pads per hour.
The Correct Answer is C
Choice A rationale
Unilateral lower leg pain is not a normal finding postpartum and could indicate a deep vein thrombosis, which requires immediate medical attention.
Choice B rationale
A soft, spongy fundus is not a normal finding postpartum. The uterus should be firm to prevent excessive bleeding.
Choice C rationale
A pulse rate of 56 beats/minute can be a normal finding postpartum. Pregnancy increases blood volume and cardiac output, and these changes can persist for some time after delivery.
Choice D rationale
Saturating two perineal pads per hour is not a normal finding postpartum and could indicate excessive bleeding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
While shallow and irregular respirations can be a sign of respiratory distress in newborns, it is not the most indicative symptom. Newborns naturally have irregular breathing patterns, which can include periods of rapid breathing followed by periods of no breathing for up to 10 seconds.
Choice B rationale
A respiratory rate of 50 breaths per minute is within the normal range for a newborn. Newborns typically breathe at a rate of 40 to 60 breaths per minute.
Choice C rationale
Flaring of the nares, or nostrils, is a common sign of respiratory distress in newborns. It indicates that the baby is working hard to breathe.
Choice D rationale
Abdominal breathing with synchronous chest movement is normal in newborns. It is not a sign of respiratory distress.
Correct Answer is A
Explanation
Choice A rationale
A client who is 3 weeks postpartum and feeling tired all the time is a common scenario. Adjusting to a new baby can be challenging and it’s normal for new mothers to feel overwhelmed and fatigued. The nurse’s response should be empathetic and supportive,
encouraging the client to share more about her situation. This could help the nurse understand the client’s support system and provide appropriate advice or resources.
Choice B rationale
While it’s important to ensure that the client isn’t overexerting herself with chores, suggesting that she shouldn’t be doing any at all might not be practical or feasible. The presence and involvement of family members can vary greatly, and while their help can be beneficial, it’s not the only factor in managing postpartum fatigue.
Choice C rationale
It’s indeed common for new mothers to feel worn out for the first few months. However, simply advising the client to rest when the baby is sleeping might not address the root cause of her fatigue. It’s also important to consider other factors such as nutrition, emotional well- being, and available support.
Choice D rationale
Telling the client that it’s normal to feel fatigued for the first few weeks might minimize her feelings. Each person’s postpartum experience is unique, and it’s crucial to validate her feelings and provide individualized care.
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