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 C
Explanation
Choice A rationale
Avoiding sexual relations for 3 days is not sufficient advice for a client diagnosed with a sexually transmitted infection (STI). The client should abstain from sexual activity until they and their partner(s) have completed treatment and are symptom-free.
Choice B rationale
Even if a sexual partner has no symptoms, they could still be infected and require treatment. Many STIs can be asymptomatic, meaning they do not show symptoms, but can still be transmitted to others.
Choice C rationale
Returning in 6 months for retesting is a good practice for individuals diagnosed with an STI. Some infections, like chlamydia and gonorrhea, should be retested about 3 months after treatment. Other infections, like HIV, might need a follow-up test 6 months later to confirm the results.
Choice D rationale
The treatment for STIs varies depending on the specific infection. Not all STIs are treated with a single dose of erythromycin. For example, gonorrhea is typically treated with an injection of ceftriaxone and oral azithromycin.
Correct Answer is D
Explanation
Choice A rationale
Excessive uterine enlargement is a common finding in a client with a hydatidiform mole. This is due to the overgrowth of trophoblastic tissue, which forms the placenta.
Choice B rationale
Profuse, clear vaginal discharge is not typically associated with a hydatidiform mole. The most common symptom is vaginal bleeding, which can be dark brown or bright red, and sometimes is described as looking like prune juice.
Choice C rationale
An irregular fetal heart rate is not a typical finding in a client with a hydatidiform mole, as this condition often results in a nonviable pregnancy.
Choice D rationale
A rapid decline in human chorionic gonadotropin (hCG) levels is not expected in a client with a hydatidiform mole. In fact, hCG levels are usually abnormally high in these cases.
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