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 ["A","E"]
Explanation
Choice A rationale
A cesarean section will be necessary if vaginal lesions are present at the time of labor. This is to prevent the transmission of the herpes virus to the baby during delivery, which can lead to serious complications such as neonatal herpes, a potentially deadly infection.
Choice B rationale
While sitz baths can help alleviate the discomfort caused by genital herpes lesions, they do not directly protect the fetus from herpes infection. The primary purpose of sitz baths in this context is to provide symptomatic relief to the mother.
Choice C rationale
The newborn will not necessarily be observed and treated in the neonatal intensive care unit just because the mother has genital herpes. The need for neonatal intensive care would depend on various factors, including whether the baby contracts the virus during delivery.
Choice D rationale
Total abstinence from sexual intercourse is not necessary during the entire pregnancy. However, it is recommended to abstain from sexual intercourse during active outbreaks to reduce the risk of transmission.
Choice E rationale
Daily administration of Valacyclovir (Valtrex) is necessary after the 36th week of pregnancy. This is known as suppressive therapy, which can help reduce the risk of an outbreak at the time of delivery and thereby reduce the risk of transmitting the virus to the baby.
Correct Answer is B
Explanation
Choice A rationale
Encouraging the client to perform Kegel exercises can help strengthen pelvic floor muscles, but it does not address the immediate problem of a displaced and boggy uterus.
Choice B rationale
Assisting the client to the bathroom to void is the correct action. A full bladder can displace the uterus and prevent it from contracting properly, which can lead to uterine atony and increased risk of postpartum hemorrhage.
Choice C rationale
Asking the client to rate her pain is important, but it does not address the immediate problem of a displaced and boggy uterus.
Choice D rationale
Encouraging the client to move to the left lateral position can improve venous return and cardiac output, but it does not address the immediate problem of a displaced and boggy uterus
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