A nurse is assessing a client who is 4 hr postpartum following a vaginal delivery. Which of the following findings should the nurse identify as the priority?
Fundus at level of umbilicus
Saturated perineal pad in 30 min
Approximated edges of episiotomy
Deep tendon reflexes 4+
The Correct Answer is D
A. Fundus is at level of the umbilicus is well contracted and therefore, not of concern.
B. A saturated perineal pad in 15 min or less can indicate excessive bleeding.
C. Approximated edges of episiotomy indicate proper wound repair and therefore, not of concern.
D. Deep Tendon reflexes 4+ -4+ are hyperactive and indicate the client is at greatest risk for preeclampsia and seizures; this is the priority.
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Related Questions
Correct Answer is B
Explanation
Rubella immunization is typically recommended for women who do not have immunity to rubella, especially before they become pregnant or during their next attempt to get pregnant. Rubella infection during pregnancy can lead to serious complications for the developing fetus, including congenital rubella syndrome, which can cause birth defects such as deafness, blindness, and heart abnormalities. Therefore, it is essential for women to be immunized against rubella to prevent these complications before becoming pregnant. It is not recommended to administer live vaccines such as the rubella vaccine during pregnancy due to the potential risk to the fetus.
Correct Answer is ["C","D","E"]
Explanation
Visual disturbances in a pregnant client could indicate conditions such as preeclampsia or gestational hypertension, which require immediate medical attention.
Monitoring the fetal heart rate is essential to assess fetal well-being, and any abnormalities in the fetal heart rate may require further evaluation by the provider.
Changes in blood pressure, especially elevated blood pressure, may indicate gestational hypertension or preeclampsia, which require monitoring and management by the provider. A significant weight gain of 3.2 kg (7 lb) over the last 2 weeks may indicate fluid retention or other issues that need assessment and intervention by the provider.
Deep tendon reflexes (option A) are not typically assessed routinely in antepartum care unless there are specific indications, such as signs of preeclampsia.
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