A nurse is assessing a client who is 4 hours postpartum following a vaginal delivery. Which of the following findings should the nurse identify as the priority?

Fundus at the level of the umbilicus

Deep tendon reflexes 4+

Saturated perineal pad in 30 minutes

Approximated edges of the episiotomy

Answer and Explanation

The Correct Answer is C

Choice A rationale
A fundus at the level of the umbilicus is a normal finding for a woman who is 4 hours postpartum.
Choice B rationale
Deep tendon reflexes of 4+ could indicate hyperreflexia, a sign of preeclampsia, but this is not the priority if the client has a saturated perineal pad in 30 minutes.
Choice C rationale
A saturated perineal pad in 30 minutes indicates heavy bleeding, which could be a sign of postpartum hemorrhage. This is a life-threatening condition and is therefore the priority.
Choice D rationale
Approximated edges of the episiotomy is a normal finding in a woman who is 4 hours postpartum.

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Correct Answer is C

Explanation

Choice A rationale
While it’s important to report concerns to the primary care provider, this does not directly address the mother’s concern about her newborn’s crossed eyes.
Choice B rationale
Strabismus is a condition where the eyes do not properly align with each other, but it is not the same as the normal crossing of a newborn’s eyes.
Choice C rationale
This is the correct answer. Newborns often lack the muscle control to regulate eye movement, which can cause their eyes to cross.
Choice D rationale
Taking the baby to the nursery for further examination may be necessary if there are other concerns, but it does not directly address the mother’s concern about her newborn’s crossed eyes.

Correct Answer is ["0.8"]

Explanation

Step 1 is to determine the amount of heparin to administer. The client is receiving 3,800 units of heparin, and the available heparin is 5,000 units/mL.
Step 2 is to set up the calculation: (3,800 units ÷ 5,000 units/mL) = x mL.
Step 3 is to perform the calculation: x = 0.76 mL. Therefore, the nurse should administer 0.8 mL of heparin, rounded to the nearest tenth.

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A nurse is assessing a client who is 4 hours postpartum following a vaginal delivery. Which of the following findings should the nurse identify as the priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a new mother who is worried about her newborn’s crossed eyes. Which of the following responses by the nurse would be therapeutic?

Correct Answer is C

Explanation

A nurse is caring for a client who is receiving heparin 3,800 units subcutaneously daily. Available is heparin 5,000 units/mL. How many ml should the nurse administer? (Round the answer to the nearest tenth.) .

Correct Answer is ["0.8"]

Explanation

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