Which of the following findings should alert a nurse assessing a client who is 8 hr postpartum and multiparous?
Fundus three fingerbreadths above the umbilicus.
Moderate lochia rubra.
Blood pressure 130/84 mm Hg.
Moderate swelling of the labia.
The Correct Answer is A
Choice A rationale
A fundus that is three fingerbreadths above the umbilicus 8 hours postpartum is a sign of urinary retention, which can displace the uterus and inhibit uterine contraction, leading to postpartum hemorrhage.
Choice B rationale
Moderate lochia rubra, or bloody discharge, is normal within the first few days after childbirth.
Choice C rationale
A blood pressure of 130/84 mm Hg is within the normal range for a postpartum woman.
Choice D rationale
Moderate swelling of the labia can be a normal finding after a vaginal birth.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Iron is an essential nutrient that helps to transport oxygen in the blood. However, it does not specifically prevent defects in the fetus.
Choice B rationale
Calcium is important for bone health in both the mother and the fetus. It does not specifically prevent defects in the fetus.
Choice C rationale
Vitamin C is an antioxidant that protects tissues from damage and helps the body absorb iron and produce collagen. While it is important for overall health, it does not specifically prevent defects in the fetus.
Choice D rationale
Folic acid is crucial in the early development of a fetus for the formation of the neural tube. It can help prevent major birth defects of the baby’s brain and spine.
Correct Answer is A
Explanation
Choice A rationale: Uteroplacental insufficiency causes late decelerations due to reduced oxygenation, not mechanical pressure. It reflects placental dysfunction, not direct cranial compression effects.
Choice B rationale: Spontaneous rupture of membranes increases infection and labor risk but does not directly alter cerebral perfusion or trigger vagal responses linked to head compression.
Choice C rationale: Altered fetal cerebral blood flow results from cranial pressure during contractions, triggering vagal stimulation and early decelerations. This is the physiological response to head compression.
Choice D rationale: Umbilical cord compression causes variable decelerations due to transient blood flow obstruction, unrelated to cranial pressure or cerebral perfusion changes.
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