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A nurse is assessing a postpartum client who delivered vaginally 8 hr ago.

Exhibit 1

Nurses' Notes

0700:

Breasts soft, nipples intact. Uterus palpated firm, midline, and at level of umbilicus. Moderate amount of lochia rubra. Episiotomy site well approximated with mild edema and ecchymosis. Client reports pain as 2 on a scale of 0 to 10. Able to void spontaneously; no bladder distention. Deep tendon reflexes 1+. Peripheral edema 2+ in bilateral lower extremities.

1100:

Breasts soft, nipples intact. Uterus palpated soft with lateral deviation and 1 cm above the umbilicus. Large amount of lochia rubra. Episiotomy site well approximated with mild edema and ecchymosis. Client reports pain as 3 on a scale of 0 to 10. Deep tendon reflexes 1+ Peripheral edema 2+ in bilateral lower extremities.

Exhibit 2

0700:

Temperature 36.2" C (97.2" F) Pulse rate 80/min

Respiratory rate 16/min

Blood pressure 136/82 mm Hg

Pulse oximetry 99%

1100:

Temperature 37.2° C (99.0° F)

Pulse rate 85/min

Respiratory rate 18/min

Blood pressure 136/86 mm Hg

Pulse oximetry 100%

Select the 3 findings that require immediate follow-up.

Uterine tone soft

Blood pressure 136/86 mm Hg

Peripheral edema 2+ bilateral lower extremities

Large amount of lochia rubra

Pain rating of 3 on a scale of 0 to 10

Breasts soft

Lateral deviation of the uterus

Answer and Explanation

Correct Answer : A,D,G

A. Uterine tone soft: A soft uterus can indicate inadequate uterine contraction, which may increase the risk of postpartum hemorrhage. The uterus should be firm and well-contracted after delivery.

B. Blood pressure 136/86 mm Hg:
A blood pressure of 136/86 mm Hg is within the normal range for a postpartum client. While changes in blood pressure should be monitored, this reading alone does not indicate an urgent need for follow-up.

C. Peripheral edema 2+ bilateral lower extremities:
Peripheral edema is a common finding in the postpartum period and is often attributed to fluid shifts and hormonal changes. While it should be monitored, it does not typically require immediate follow-up unless it is severe or associated with other symptoms.

D. Large amount of lochia rubra: While lochia rubra is normal in the first few days postpartum, a large amount could indicate potential bleeding issues or complications if it increases significantly.

E. Pain rating of 3 on a scale of 0 to 10:
A pain rating of 3 on a scale of 0 to 10 is relatively mild and may be expected after a vaginal delivery, especially if the client has undergone an episiotomy. It should be addressed but does not require immediate follow-up unless it worsens or is associated with other concerning symptoms.

F. Breasts soft:
Soft breasts are expected in the early postpartum period, particularly if the client is not breastfeeding or if breastfeeding has not yet been established. However, breastfeeding assessment and support should be provided as part of routine postpartum care.

G. Lateral deviation of the uterus:The uterus should be midline and firm. A lateral deviation could suggest a full bladder or other complications that need to be addressed to prevent further issues such as postpartum hemorrhage.

H. Deep tendon reflexes 1+:
Deep tendon reflexes of 1+ are within the normal range and do not typically require immediate follow-up unless they are absent or hyperactive, which may indicate neurological issues.

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Correct Answer is C

Explanation

A. The client cleans the perineum with a squeeze bottle after urinating:

This action is a recommended postpartum hygiene practice. Using a squeeze bottle filled with warm water to gently clean the perineum after urinating helps to promote cleanliness and prevent infection. It is important to maintain good hygiene in the perineal area to support wound healing and reduce the risk of complications.

B. The client's perineal suture line is well-approximated:

A well-approximated perineal suture line indicates that the edges of the laceration have been properly aligned and closed with sutures. This is an essential aspect of wound management, as it promotes healing by primary intention. When the wound edges are closely aligned and secured, it reduces the risk of infection and supports optimal healing.

C. The client is changing the perineal pad once daily:

Changing the perineal pad only once daily is a suboptimal practice that can contribute to delayed wound healing. Postpartum clients with perineal lacerations should change their perineal pads frequently, at least every 4 to 6 hours, to maintain cleanliness and prevent excessive moisture buildup, which can increase the risk of infection and hinder wound healing.

D. The client is using witch hazel pads on the perineum:

Witch hazel pads are commonly used for comfort and to alleviate swelling and discomfort in the perineal area after childbirth. While witch hazel pads can provide symptomatic relief, they are not typically associated with delayed wound healing when used appropriately. However, it's essential to ensure that the perineal area remains clean and dry to promote optimal wound healing and prevent complications.

A. “I should avoid breastfeeding for 2 weeks following the immunization." B. "I should avoid becoming pregnant for at least 1 month following the immunization." C. "I will report joint pain that develops after the immunization to my provider immediately." D. "I will receive a series of three immunizations and each one will be a month apart."

Correct Answer is B

Explanation

A. "I should avoid breastfeeding for 2 weeks following the immunization."

This statement is incorrect. There is no need to avoid breastfeeding after receiving the rubella vaccine. Breastfeeding is safe and not contraindicated following immunization with the rubella vaccine. Breastfeeding can continue as usual without interruption.

B. "I should avoid becoming pregnant for at least 1 month following the immunization."

This statement is correct. Following administration of the rubella vaccine, it is recommended to avoid becoming pregnant for at least 1 month. This precaution is due to theoretical concerns about the vaccine potentially affecting the developing fetus if a woman were to become pregnant shortly after vaccination. Rubella infection during pregnancy can cause serious birth defects, so it's important to take precautions to avoid potential harm to the fetus.

C. "I will report joint pain that develops after the immunization to my provider immediately."

While joint pain can be a rare side effect of the rubella vaccine, it is not typically necessary to report it immediately unless it is severe or persistent. Mild joint pain is a common and expected side effect of some vaccines, including the rubella vaccine, and typically resolves on its own without intervention. However, if joint pain is severe or persistent, it may be appropriate to report it to a healthcare provider for further evaluation and management.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is postpartum and has a perineal laceration. Which of the following findings places the client at risk for delayed wound healing?

Correct Answer is C

Explanation

A nurse is providing teaching to a postpartum client who has a prescription for a rubella immunization. Which of the following client statements Indicates understanding of the teaching?

Correct Answer is B

Explanation

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A nurse is assessing a client who is 1 hr postpartum. Which of the following findings should the nurse report to the provider?

A nurse is caring for a newborn who has jaundice and a new prescription for phototherapy. Which of the following actions should the nurse take?

A nurse is caring for a client in labor who has herpes simplex virus (HSV) with active lesions. Which of the following interventions should the nurse plan to implement to prevent the transmission of HSV to the newborn?

A nurse is assessing a newborn who is 2 hr old. Which of the following findings is an indication of hypoglycemia? (Select all that apply.)

A nurse is assessing a client who is 6 hr postpartum and is saturating perineal pads every 10 to 15 min. Which of the following actions should the nurse take first?

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