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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The priority nursing goal is to maintain the integrity of the sac.
Myelomeningocele is a type of spina bifida where the spinal cord and its covering (meninges) protrude through an opening in the vertebrae, forming a sac on the baby's back. It is crucial to protect this sac from injury and infection to prevent complications such as meningitis and nerve damage.
Correct Answer is B
Explanation
A. The client is experiencing postpartum depression. A prescription of antidepressants is important but should come after fully assessing the client's mental state
B. Asking the client if she has considered harming her newborn is important in further assessments to establish the mothers as it is a common feature of postpartum depression.
C. While reinforcing education on postpartum and newborn care is important for overall maternal and infant well-being, it may not directly address the client's current mental health concerns.
D. Exploring options on how to help the client is key but this should comer after a thorough examination has occurred.
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