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 D

Explanation

Choice A rationale
Amniocentesis is not a surgical procedure that requires general anesthesia, so the client will not be asleep during the procedure.
Choice B rationale
Fasting is not typically required before an amniocentesis. The procedure involves inserting a thin needle into the amniotic sac to withdraw a small amount of fluid for testing. It does not involve the digestive system, so there is no need for the client to fast.
Choice C rationale
While the client may be in various positions during the procedure, lying on the side is not typically required. The position of the client during the procedure is determined by the location of the baby and the amniotic sac.
Choice D rationale
Emptying the bladder before the procedure can make it easier for the healthcare provider to access the uterus and amniotic sac. Therefore, this statement indicates an understanding of the teaching.

A. A client who has gestational diabetes mellitus B. A client who had a previous stillbirth C. A client who had a nonreactive nonstress test D. A client who has a previous classical incision

Correct Answer is D

Explanation

Choice A rationale
Gestational diabetes mellitus is not a contraindication for a contraction stress test. This condition affects how the mother’s body uses glucose (sugar) during pregnancy, but it does not interfere with the ability to perform a contraction stress test.
Choice B rationale
A previous stillbirth is not a contraindication for a contraction stress test. A stillbirth refers to the loss of a baby after 20 weeks of pregnancy. While this is a significant event, it does not prevent the mother from undergoing a contraction stress test in a subsequent pregnancy.
Choice C rationale
A nonreactive nonstress test is not a contraindication for a contraction stress test. A nonreactive nonstress test indicates that the baby’s heart rate does not speed up (or “react”) as it should when the baby moves. However, this result does not prevent the mother from undergoing a contraction stress test.
Choice D rationale
A previous classical incision is a contraindication for a contraction stress test. A classical incision refers to a vertical cut in the upper part of the uterus, which is typically used during a cesarean section. This type of incision increases the risk of uterine rupture, which can be life- threatening for both the mother and the baby. Therefore, a contraction stress test, which induces contractions, should not be performed due to the risk of uterine rupture.

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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 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?

Correct Answer is D

Explanation

In a prenatal clinic, a nurse is caring for a group of clients. Which client should the nurse identify as having a contraindication for a contraction stress test?

Correct Answer is D

Explanation

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A nurse is assessing a newborn whose mother had gestational diabetes mellitus. The nurse should monitor for which of the following findings as a manifestation of hypoglycemia?

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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.