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
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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Related Questions
Correct Answer is B
Explanation
A. Bleeding tendencies:
Bleeding tendencies are not typically a priority immediately after birth unless there is a specific indication. Newborns are not at immediate risk for bleeding unless there are underlying conditions.
B. Heat loss:
Heat loss is a significant concern for newborns. Maintaining an adequate temperature is crucial to prevent hypothermia, which can lead to complications.
C. Hypoglycemia:
While monitoring blood glucose is important in the newborn, it may not be the most immediate concern within the first minutes after delivery. Stabilizing the newborn's temperature and initiating breathing are usually higher priorities.
D. Fluid balance:
Fluid balance is essential, but the initial focus is often on establishing respirations and maintaining temperature. Fluids may be administered as needed based on the clinical assessment.
Correct Answer is C
Explanation
A. Hemoglobin and hematocrit:
While monitoring hemoglobin and hematocrit levels is important for assessing blood loss, in the immediate situation of a developing perineal hematoma with severe pain and pressure, assessing vital signs takes precedence to identify any signs of circulatory compromise.
B. Abdominal contour and bowel sounds:
These assessments are not the first priority in this situation. The client's complaint of severe pain and pressure in the perineum indicates a localized issue that needs immediate attention.
C. Heart rate and blood pressure:
This is the correct answer. Assessing the client's heart rate and blood pressure is crucial to identify signs of shock or compromised circulation associated with the perineal hematoma.
D. Urinary output and IV fluid intake:
While monitoring urinary output and IV fluid intake is important for overall assessment, in the context of a perineal hematoma, assessing vital signs is more immediate to identify any signs of hemodynamic instability.
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