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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
A 21-gauge needle is too large for a heel stick on a newborn.
Choice B rationale:
Alcohol can cause skin irritation and should not be used after the procedure.
Choice C rationale:
A warm cloth, not a cool one, should be applied to the site before the procedure to enhance circulation.
Choice D rationale:
The lateral side of the heel is the correct site for a heel stick to avoid injury to the bone.
Correct Answer is B
Explanation
Choice A rationale:
Subcutaneous injections are not typically used for newborns due to their lack of subcutaneous fat.
Choice B rationale:
The vastus lateralis muscle is the preferred site for IM injections in newborns due to its size and location.
Choice C rationale:
The deltoid is not a recommended site for IM injections in newborns due to its small size.
Choice D rationale:
As mentioned earlier, subcutaneous injections are not typically used for newborns.
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