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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
While excessive fatigue and headache can occur in pregnancy, they are not typically signs of labor.
Choice B rationale
A sudden gush of clear fluid from the vagina, also known as rupture of membranes, is a sign that labor may be starting.
Choice C rationale
Sharp, right-sided abdominal pain is not a typical sign of labor. It could indicate other issues such as appendicitis.
Choice D rationale
An increased pulse rate and upper abdominal pain are not typical signs of labor.
Correct Answer is C
Explanation
Continuous contractions lasting 2 minutes could indicate uterine tetany, which could lead to uterine rupture, a life-threatening situation that requires immediate medical attention.
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