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

Exhibit 1. Nurses' Notes.

0700:. Exhibit 2. 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.

Vital Signs.

0700:. Temperature 36.2° C (97.2° F). Pulse rate 80/min.

Respiratory rate 16/min.

Blood pressure 136/82 mm Hg. Pulse oximetry 999%. 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.

Peripheral edema 2+ bilateral lower extremities.

Lateral deviation of the uterus.

Large amount of lochia rubra.

Uterine tone soft.

Breasts soft.

Deep tendon reflexes 1+.

Pain rating of 3 on a scale of 0 to 10.

Answer and Explanation

Correct Answer : B,C,D

Choice A rationale:
Peripheral edema is common in the postpartum period and does not require immediate follow-up.
Choice B rationale:
Lateral deviation of the uterus could indicate a full bladder, which requires immediate follow-up.
Choice C rationale:
Large amount of lochia rubra 8 hours postpartum could indicate postpartum hemorrhage, which requires immediate follow-up.
Choice D rationale:
A soft uterine tone could indicate uterine atony, a cause of postpartum hemorrhage, which requires immediate follow-up.
Choice E rationale:
Soft breasts are normal in the immediate postpartum period and do not require immediate follow-up.
Choice F rationale:
Deep tendon reflexes of 1+ are normal and do not require immediate follow-up.
Choice G rationale:
A pain rating of 3 on a scale of 0 to 10 is manageable and does not require immediate follow-up.
Choice H rationale:
Blood pressure of 136/86 mm Hg is slightly elevated but does not require immediate follow-up unless there are other signs of preeclampsia.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is ["D","E","H"]

Explanation

Choice A rationale:
BUN is within the normal range (10 to 20 mg/dL), so it's not an indication of a potential complication.
Choice B rationale:
Potassium is slightly below the normal range (3.5 to 5 mEq/L), indicating potential hypokalemia, which can be a complication.
Choice C rationale:
Hct is at the upper limit of the normal range (33% to 49%), but still within normal, so it's not a complication.
Choice D rationale:
Weight loss of 2 kg in 1 month during pregnancy is concerning and could indicate a complication such as hyperemesis gravidarum.
Choice E rationale:
Heart rate is slightly elevated, which could indicate dehydration, a potential complication.
Choice F rationale:
Sodium is slightly below the normal range (136 to 145 mEq/L), but this alone is not typically a complication of pregnancy.
Choice G rationale:
Hgb is within the normal range (11 to 16 g/dL), so it's not a complication.
Choice H rationale:
Urine-specific gravity is above the normal range (1.005 to 1.030), indicating potential dehydration, a complication.

A. Obtain a prescription for misoprostol. B. Assess for edema. C. Restrict daily oral fluid intake. D. Administer an IV bolus of lactated Ringer's.

Correct Answer is B

Explanation

Choice A rationale:
Misoprostol is not typically used for preeclampsia management. It’s used for cervical ripening and labor induction.
Choice B rationale:
Assessing for edema is important in a client with preeclampsia as it can indicate a worsening condition.
Choice C rationale:
Restricting daily oral fluid intake is not typically part of the management plan for preeclampsia without severe features.
Choice D rationale:
Administering an IV bolus of lactated Ringer’s is not typically part of the management plan for preeclampsia without severe features.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is at 15 weeks of gestation during a routine prenatal visit. Exhibits Which of the following findings should the nurse identify as an indication of a potential complication of pregnancy? Select all that apply.

Correct Answer is ["D","E","H"]

Explanation

A nurse is planning care for a client who is 1 hr postpartum and has preeclampsia without severe features. Which of the following actions should the nurse plan to take?

Correct Answer is B

Explanation

A nurse is providing teaching about the expected effects of magnesium sulfate to a client who is at 28 weeks of gestation and has preeclampsia. Which of the following responses by the nurse is appropriate?

A nurse is providing teaching to a new parent about findings that require notification of the newborn's provider. Which of the following newborn clinical manifestations should the nurse include in the teaching?

A nurse in a clinic is caring for an adolescent client who requests a prescription for birth control. Which of the following questions should the nurse ask?

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?

A nurse is assisting the provider to administer a dinoprostone insert to induce labor for a client. Which of the following actions should the nurse take?

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?

A nurse is reviewing the history of a client who is pregnant. Which of the following clinical data indicates the client is at risk for preterm delivery?

A nurse is caring for a client who is in the third stage of labor and has a prescription for IV oxytocin administration following expulsion of the placenta. Which of the following clinical manifestations should the nurse expect as a therapeutic effect of the medication?