A nurse is assessing a client who is 1 hour postpartum.
Which of the following findings should the nurse report to the provider?
Temperature 37.7° C (99.9° F).
Boggy fundus.
Lochia rubra with small clots.
Minimal perineal edema.
The Correct Answer is B
Choice A rationale
A temperature of 37.7° C (99.9° F) in the immediate postpartum period is a relatively common and often benign finding, typically within normal limits or indicating mild dehydration or exertion from labor. A slight elevation is not usually a cause for immediate concern unless accompanied by other signs of infection, which would warrant further investigation. Normal range is 36.5° C to 37.5° C (97.7° F to 99.5° F).
Choice B rationale
A boggy fundus is a significant finding that the nurse should report immediately. A boggy, soft uterus indicates uterine atony, which means the uterine muscles are not contracting effectively. This significantly increases the risk of postpartum hemorrhage due to inadequate compression of uterine blood vessels.
Choice C rationale
Lochia rubra with small clots is considered a normal finding in the immediate postpartum period. Lochia rubra is the initial dark red discharge consisting of blood, decidual tissue, and mucus. Small clots are expected as blood clots and detaches from the uterine wall, reflecting normal uterine involution.
Choice D rationale
Minimal perineal edema is a normal and expected finding after vaginal delivery. The trauma of childbirth often results in some degree of swelling in the perineal area. "Minimal" edema indicates that the swelling is not excessive and does not suggest a complication requiring immediate reporting to the provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
The vaginal contraceptive ring is designed for cyclic use, specifically to be left inserted for 3 consecutive weeks, followed by a 1-week ring-free interval. This regimen allows for a withdrawal bleed during the ring-free week, mimicking a natural menstrual cycle while maintaining contraceptive efficacy by providing continuous hormone release for 21 days.
Choice B rationale
Body weight fluctuations of 4.5 kg (10 lb) do not significantly impact the effectiveness of the vaginal contraceptive ring. The ring delivers a localized and consistent dose of hormones that is not dependent on systemic absorption influenced by minor weight changes. Therefore, contacting a provider for a new ring due to this weight change is unnecessary.
Choice C rationale
The vaginal contraceptive ring should not be washed with soap and water after each use. The ring is a single-use, disposable device designed to be inserted and remain in place for the full 3-week duration. Washing it could potentially degrade the material or interfere with the controlled release of hormones, compromising its efficacy.
Choice D rationale
The vaginal contraceptive ring does not need to be inserted immediately before sexual intercourse. It provides continuous contraceptive protection as long as it is inserted and used correctly according to the 3-week in, 1-week out schedule. Its efficacy is not tied to the timing of individual sexual acts.
Correct Answer is ["A","B"]
Explanation
Choice A rationale
Diphtheria-acellular pertussis (Tdap) vaccine is recommended for pregnant clients during the third trimester, specifically between 27 and 36 weeks of gestation. This timing optimizes the transfer of maternal antibodies to the fetus, providing passive immunity against pertussis (whooping cough) in the newborn during their vulnerable early months, before they are old enough to receive their own vaccinations.
Choice B rationale
Inactivated influenza vaccine is highly recommended for pregnant clients during any trimester of pregnancy. Pregnancy alters the immune system, making pregnant individuals more susceptible to severe complications from influenza. Vaccination protects both the mother and, through passive antibody transfer, the newborn from influenza infection.
Choice C rationale
Varicella vaccine is a live attenuated vaccine and is contraindicated during pregnancy due to the theoretical risk of fetal infection. While the actual risk is very low, it is generally deferred until the postpartum period. Women of childbearing age should be screened for immunity and vaccinated if non-immune prior to conception or postpartum.
Choice D rationale
Measles, mumps, and rubella (MMR) vaccine is a live attenuated vaccine and is contraindicated during pregnancy due to the theoretical risk of fetal infection, particularly with rubella. Rubella infection during pregnancy can lead to congenital rubella syndrome, causing severe birth defects. Vaccination should occur before conception or postpartum.
Choice E rationale
Human papillomavirus (HPV) vaccine is not routinely recommended during pregnancy. While current data do not suggest harm, the vaccine has not been extensively studied in pregnant individuals. Vaccination should be completed before pregnancy or deferred until the postpartum period.
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