A client who is a gravida 5, para 5 client delivers a 10-pound (4,540 gram) infant.
In planning postpartum care, which assessment has the highest priority?
Uterine muscle tone.
Vulvo-perineal tissues and episiotomy.
Body temperature.
Breast engorgement and nipple integrity.
The Correct Answer is A
Choice A rationale
Uterine muscle tone is the highest priority assessment postpartum, especially after a large infant delivery. A boggy uterus indicates uterine atony, a leading cause of postpartum hemorrhage. The uterus must contract firmly to compress blood vessels and prevent excessive bleeding. Prompt intervention is crucial to prevent hypovolemic shock. Normal uterine tone is firm and midline.
Choice B rationale
Vulvo-perineal tissues and episiotomy assessment is important to identify hematomas or excessive swelling. While significant, these are typically less life-threatening in the immediate postpartum period compared to uterine atony. Hematomas can cause pain and pressure, and wound integrity is vital for infection prevention.
Choice C rationale
Body temperature assessment is important to detect fever, which could indicate infection. Postpartum infection is a concern, but hypovolemic shock from hemorrhage is a more immediate and critical threat to maternal well-being. Normal postpartum temperature is typically below 38°C (100.4°F).
Choice D rationale
Breast engorgement and nipple integrity are important for promoting successful breastfeeding and preventing complications like mastitis. However, these are not immediate life-threatening concerns in the initial hours after delivery. Early assessment focuses on maternal physiological stability.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Gravida refers to the total number of pregnancies a woman has had, regardless of outcome. The client has had a pregnancy that resulted in a miscarriage at 16 weeks, a pregnancy that resulted in fetal demise at 31 weeks, and the current pregnancy at 39 weeks. Therefore, the total number of pregnancies is 3. The gravida is 3.
Correct Answer is D
Explanation
Choice A rationale
An acceleration is a visually apparent abrupt increase in the fetal heart rate above the baseline. For a 38-week fetus, an acceleration is defined as an increase of 15 beats per minute or more above the baseline, lasting 15 seconds or more but less than 2 minutes. The given finding of 10 seconds does not meet this criterion.
Choice B rationale
While fetal movement often accompanies accelerations, documenting "fetal movement" alone is insufficient. The nonstress test specifically assesses the fetal heart rate response to movement, and the critical finding to document relates to the FHR pattern itself, not just the presence of movement.
Choice C rationale
A positive tracing in obstetrics typically refers to a positive contraction stress test, which indicates late decelerations and is an abnormal finding. This terminology is not applicable to a nonstress test, where the terms "reactive" or "nonreactive" are used to describe the findings.
Choice D rationale
A nonreactive pattern on a nonstress test for a 38-week fetus is defined by the absence of two or more accelerations (15 bpm above baseline for at least 15 seconds) within a 20-minute period. The observed FHR increases lasting only 10 seconds do not meet the duration criteria for reactivity.
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