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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 ["B","D","E"]

Explanation

Choice A rationale:
Abdominal distention is not typically a sign of hypoglycemia in a newborn. It could be related to other factors such as feeding issues or gastrointestinal problems.
Choice B rationale:
Jitteriness can be a sign of hypoglycemia in a newborn as low blood sugar can cause nervous system hyperactivity.
Choice C rationale:
Acrocyanosis, or bluish discoloration of the hands and feet, is common in newborns and is not typically a sign of hypoglycemia.
Choice D rationale:
Hypotonia, or decreased muscle tone, can be a sign of hypoglycemia in a newborn as low blood sugar can affect muscle function.
Choice E rationale:
Temperature instability can be a sign of hypoglycemia in a newborn as low blood sugar can affect the body’s ability to regulate temperature.

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

Correct Answer is D

Explanation

Choice A rationale:
Breastfeeding is not contraindicated following rubella immunization, so this statement is incorrect.
Choice B rationale:
The rubella vaccine is a single-dose vaccine, not a series of three.
Choice C rationale:
Joint pain can occur following rubella immunization, but it’s not a severe side effect that requires immediate medical attention.
Choice D rationale:
Women are advised to avoid pregnancy for at least 1 month following rubella immunization due to the theoretical risk to the fetus, so this statement is correct.

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Naxlex Comprehensive Predictor Exams

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.).

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

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 D

Explanation

A nurse is assessing a client who is in labor and has received epidural analgesia. Which of the following findings should the nurse recognize and document as an adverse effect of epidural analgesia?

A nurse is assessing a full-term newborn upon admission to the nursery. Which of the following clinical findings should the nurse report to the provider?

A nurse is caring for a client who is experiencing an amniotic fluid embolism during labor. Which of the following actions should the nurse take?

A nurse is caring for a client who is at 32 weeks of gestation and has placenta previa. The client is exhibiting a large amount of vaginal bleeding. Which of the following actions should the nurse take?

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 is caring for a newborn who was born at 39 weeks of gestation and is 36 hours old. Exhibits Which of the following findings should the nurse report to the provider? Select all that apply.