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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Fetal head compression is typically caused by uterine contractions during labor. As the uterine muscles get tighter and shorter, the size of the uterus decreases, thereby limiting the available space for the fetus.
Choice B rationale
Spontaneous rupture of membranes is not typically associated with fetal head compression.
Choice C rationale
Altered fetal cerebral blood flow is not typically associated with fetal head compression.
Choice D rationale
Umbilical cord compression is typically associated with variable decelerations in the FHR, not fetal head compression.
Correct Answer is D
Explanation
Choice A rationale
The left lower quadrant is not the most likely location to auscultate fetal heart tones if the nurse palpates a round, firm, movable part in the fundus of the uterus and a long, smooth surface on the client’s right side. These findings suggest that the fetus is in a breech position with its back on the left side, which would place the fetal chest, and thus the heart tones, in the right lower quadrant.
Choice B rationale
The right upper quadrant is not the most likely location to auscultate fetal heart tones if the nurse palpates a round, firm, movable part in the fundus of the uterus and a long, smooth surface on the client’s right side. These findings suggest that the fetus is in a breech position with its back on the left side, which would place the fetal chest, and thus the heart tones, in the right lower quadrant.
Choice C rationale
The left upper quadrant is not the most likely location to auscultate fetal heart tones if the nurse palpates a round, firm, movable part in the fundus of the uterus and a long, smooth surface on the client’s right side. These findings suggest that the fetus is in a breech position with its back on the left side, which would place the fetal chest, and thus the heart tones, in the right lower quadrant.
Choice D rationale
The right lower quadrant is the most likely location to auscultate fetal heart tones if the nurse palpates a round, firm, movable part in the fundus of the uterus and a long, smooth surface on
the client’s right side. These findings suggest that the fetus is in a breech position with its back on the left side, which would place the fetal chest, and thus the heart tones, in the right lower quadrant.
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