A nurse has been monitoring a client who gave birth vaginally 8 hours ago.

Based on the nurse’s notes at 0700 and 1100, select the three findings that necessitate immediate follow-up.

Peripheral edema 2+ in bilateral lower extremities

Blood pressure reading of 136/86 mm Hg

Lateral deviation of the uterus

Deep tendon reflexes 1+

Large amount of lochia rubra .

Answer and Explanation

Correct Answer : B,C,E

Choice A rationale
Peripheral edema 2+ in bilateral lower extremities is a common finding in the postpartum period and does not necessarily indicate a problem. It can result from the normal fluid shifts that occur after delivery.
Choice B rationale
A blood pressure reading of 136/86 mm Hg is slightly elevated and could indicate the development of postpartum hypertension, a condition that can lead to serious complications such as stroke. This finding necessitates immediate follow-up.
Choice C rationale
Lateral deviation of the uterus could indicate a full bladder, which can interfere with uterine contractions and lead to increased bleeding. This finding necessitates immediate follow-up.
Choice D rationale
Deep tendon reflexes 1+ are within normal limits and do not necessitate immediate follow-up.
Choice E rationale
A large amount of lochia rubra could indicate postpartum hemorrhage, a potentially life- threatening condition. This finding necessitates immediate follow-up.

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Correct Answer is A

Explanation

Choice A rationale
In the case of intrauterine fetal demise at 36 weeks of gestation, the most common treatment option is induction of labor.
Choice B rationale
An immediate cesarean birth is typically not the first choice of treatment for intrauterine fetal demise unless there are other complications.
Choice C rationale
Methotrexate is used to treat ectopic pregnancies, not intrauterine fetal demise.
Choice D rationale
Dilation with suction curettage is typically used for early pregnancy loss, not late-term intrauterine fetal demise.

A. Preterm newborns might have a thick layer of brown fat that can cause them to quickly become overheated. B. Preterm newborns might shiver to warm up when they get too cool. C. Preterm newborns might sweat to cool off when they get too warm. D. Preterm newborns might have less muscle tone which exposes more body surfaces to heat loss.

Correct Answer is D

Explanation

Choice A rationale
Preterm newborns do not have a thick layer of brown fat. Brown fat is a type of fat that generates heat and is typically found in full-term newborns. It helps them maintain their body temperature. Preterm newborns have less brown fat, which makes them more susceptible to hypothermia.
Choice B rationale
Shivering is a mechanism used by the body to generate heat when it’s cold. However, preterm newborns cannot shiver. Their nervous systems are not fully developed, and they lack the muscle coordination necessary to shiver.
Choice C rationale
Sweating is another mechanism the body uses to regulate temperature. When the body is too warm, it produces sweat to cool down. However, preterm newborns do not sweat to cool off when they get too warm. Their sweat glands are not fully developed, and they may not be able to sweat effectively.
Choice D rationale
Preterm newborns have less muscle tone, which exposes more body surfaces to heat loss. Muscle tone provides insulation and generates heat. Because preterm newborns have less muscle mass, they have less insulation and generate less heat, making them more susceptible to hypothermia.

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A nurse has been monitoring a client who gave birth vaginally 8 hours ago. Based on the nurse’s notes at 0700 and 1100, select the three findings that necessitate immediate follow-up.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

“A nurse is caring for a patient who is at 36 weeks of gestation and has a confirmed intrauterine fetal demise. Which of the following treatment options should the nurse anticipate the provider to discuss with the patient?”

Correct Answer is A

Explanation

A nurse is providing teaching to the guardians of a preterm newborn about temperature instability. Which of the following statements should the nurse make?

Correct Answer is D

Explanation

A nurse is teaching about home safety with a client who is 2 days postpartum. Which of the following instructions should the nurse include in the teaching?

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A nurse is providing teaching to a client who is at 35 weeks of gestation and has a prescription for an amniocentesis. Which of the following client statements indicates an understanding of the teaching?

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A nurse has been monitoring a client who gave birth vaginally 8 hours ago. Based on the nurse’s notes at 0700 and 1100, select the three findings that necessitate immediate follow-up.

A nurse is planning care for a client who is 1 hour postpartum and has peripartum cardiomyopathy. Which of the following actions should the nurse plan to take?

A nurse has been monitoring a client who gave birth vaginally 8 hours ago.

Based on the nurse’s notes at 0700 and 1100, select the three findings that necessitate immediate follow-up.