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
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Correct Answer is B
Explanation
Lochia rubra, which is bright red and may contain small clots, is the normal postpartum vaginal discharge that occurs during the first few days after childbirth. It indicates the shedding of the uterine lining and is expected during the early postpartum period. A midline and firm fundus at the level of the umbilicus suggests appropriate uterine involution, indicating that the uterus is contracting effectively to expel lochia and decrease in size.
Given these findings, there is no immediate concern requiring intervention.
Correct Answer is D
Explanation
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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