Which 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

Saturating two perineal pads per hour.

Pulse rate of 56 beats/minute

Answer and Explanation

The Correct Answer is D

A. Unilateral lower leg pain:
Unilateral lower leg pain can be a symptom of deep vein thrombosis (DVT), which is a serious condition. It requires further assessment and intervention.

B. Soft, spongy fundus:
A soft, spongy fundus is not a normal finding 12 hours postpartum. The fundus should be firm and well-contracted. A soft fundus could indicate uterine atony, a potential cause of postpartum hemorrhage.

C. Saturating two perineal pads per hour:
Saturating two perineal pads per hour is not a normal finding and may indicate excessive bleeding, which is concerning for postpartum hemorrhage. This requires immediate attention.

D. Pulse rate of 56 beats/minute:
A pulse rate of 56 beats per minute can be within the normal range, especially if the client is at rest. However, it's essential to consider the overall clinical picture and whether there are any signs of distress or symptoms associated with a low pulse rate.

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Correct Answer is C

Explanation

A. Notify the healthcare provider of the complaint: While it's important for the healthcare provider to be aware of any changes or symptoms the client is experiencing, the described discharge is commonly associated with normal physiological changes in pregnancy.

B. Recommend an over-the-counter yeast medication: The characteristics of the discharge described (white, thin, and watery) are not typical of a yeast infection. Using over-the-counter medications without proper assessment can lead to unnecessary treatment.

C. Inform her that this is a normal physiological change: This is the most appropriate action. Increased vaginal discharge, often described as leukorrhea, is a common and normal change during pregnancy. It's generally thin, white, and watery.

D. Prepare the client for a sterile speculum exam: A sterile speculum exam may be indicated if there are other concerning symptoms or if the discharge changes in color, consistency, or if there is associated itching or foul odor. However, based on the information provided, it's not the first-line action.

A. Obtain blood and urine for prenatal screens B. Explain common complications of pregnancy C. Obtain baseline blood pressure and weight D. Schedule prenatal visits to occur monthly

Correct Answer is A

Explanation

A. Obtain blood and urine for prenatal screens.
This choice is important because it allows the nurse to assess the client's overall health, screen for infections, and identify any potential risks or complications that may impact the pregnancy.

B. Explain common complications of pregnancy.
While educating the client about common complications is valuable, it may not address the immediate need to screen for specific infections or assess the client's current health status. This information can be covered during prenatal education sessions.

C. Obtain baseline blood pressure and weight.
This is a routine part of prenatal care and is important for monitoring the client's health throughout pregnancy. However, if the client has a history of syphilis, obtaining specific prenatal screens (including for syphilis) would be a more targeted and immediate action.

D. Schedule prenatal visits to occur monthly.
Scheduling regular prenatal visits is essential for monitoring the progression of the pregnancy. However, addressing the specific health concerns and obtaining necessary screens take precedence during the initial visit, especially considering the client's history of syphilis.

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Which physical assessment data should the nurse consider a normal finding for a primigravida client who is 12 hours postpartum?

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Naxlex Comprehensive Predictor Exams

During a routine first trimester prenatal exam, a pregnant client tells the nurse that she has noticed an increase in vaginal discharge that is white, thin, and watery. Which action should the nurse implement?

Correct Answer is C

Explanation

The nurse is reviewing a woman's health care record during her first prenatal visit. The client has a history of chicken pox as a child and syphills as a teenager. Which action is most important for the nurse to take?

Correct Answer is A

Explanation

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