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A nurse is assisting with the care of a postpartum client who delivered vaginally 8 hr ago.

Exhibits

Select the 3 findings that require immediate follow-up.

Blood pressure 136/86 mm Hg

Peripheral edema 2+ bilateral lower extremities

Lateral deviation of the uterus

Breasts soft

Pain rating of 3 on a scale of 0 to 10

Uterine tone soft

Large amount of lochia rubra

Deep tendon reflexes 1+

Answer and Explanation

Correct Answer : C,F,G

A. Blood pressure 136/86 mm Hg
- The blood pressure reading is slightly elevated but not critically high. Postpartum hypertension can be a concern, but this level does not indicate an immediate risk.
- This reading is consistent with the earlier measurement, suggesting stability.
- Immediate follow-up is not required unless there is a significant increase or additional symptoms are present.
B. Peripheral edema 2+ bilateral lower extremities
- Edema is common in the postpartum period due to fluid shifts and should resolve naturally.
- The consistent 2+ rating indicates no acute change.
- Monitoring is appropriate, but it does not require immediate follow-up unless it worsens or is accompanied by other symptoms.
C. Lateral deviation of the uterus
- A laterally deviated uterus can indicate a displaced uterus, possibly due to a full bladder or other reasons, which requires prompt attention.
- The deviation from the firm, midline position noted earlier could suggest an underlying issue that needs immediate investigation.
- This finding could lead to complications if not addressed promptly.
D. Breasts soft
- Soft breasts are normal postpartum when milk has not yet come in or if the client is not breastfeeding.
- There is no change from the earlier assessment.
- This does not require immediate follow-up as it is a normal finding.
E. Pain rating of 3 on a scale of 0 to 10
- A pain rating of 3 is mild and manageable, especially considering it was 2 earlier.
- This slight increase in pain is expected and can be monitored with routine care.
- It does not necessitate immediate follow-up unless there is a sudden and significant increase in pain.
F. Uterine tone soft
- A soft uterine tone postpartum can indicate uterine atony, which can lead to hemorrhage.
- The change from a previously firm uterus to a soft one is concerning.
- Immediate follow-up is necessary to prevent potential complications such as postpartum hemorrhage.
G. Large amount of lochia rubra
- A large amount of lochia rubra can be a sign of excessive bleeding.
- The increase from a moderate amount earlier to a large amount could indicate a hemorrhagic complication.
- This finding requires immediate follow-up to assess for postpartum hemorrhage.
H. Deep tendon reflexes 1+
- A deep tendon reflex of 1+ is considered within normal limits.
- There has been no change from the earlier assessment.
- This finding does not require immediate follow-up as it is a normal finding.

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Correct Answer is D

Explanation

A. Leukorrhea, a normal increase in vaginal discharge, is a common and expected finding during pregnancy. It usually does not require immediate medical intervention unless accompanied by other symptoms.
B. Gingivitis is a common issue during pregnancy due to hormonal changes, but it is generally managed with good oral hygiene and routine dental care. It is not an urgent finding compared to other conditions.
C. Varicose veins are a common condition during pregnancy due to increased blood volume and pressure on the veins. While they can be uncomfortable, they are generally managed through lifestyle changes and do not represent an immediate risk.
D. Dysuria, or painful urination, may indicate a urinary tract infection or another serious condition that requires prompt medical attention. It can lead to complications if untreated, so it is a priority finding that needs to be reported to the provider for further evaluation and treatment.

A. History of methicillin-resistant Staphylococcus aureus B. History of thrombophlebitis C. Type 1 diabetes mellitus D. History of toxic shock syndrome

Correct Answer is D

Explanation

A. A history of methicillin-resistant Staphylococcus aureus (MRSA) does not contraindicate the use of a cervical cap. MRSA is an infection issue, but the cervical cap does not pose a significant risk for MRSA-related complications.
B. A history of thrombophlebitis is not a contraindication for the use of a cervical cap. Thrombophlebitis concerns are generally associated with hormonal contraceptives rather than barrier methods like cervical caps.
C. Type 1 diabetes mellitus is not a contraindication for using a cervical cap. Individuals with Type 1 diabetes can use barrier methods for contraception, though they should manage their condition carefully for overall health.
D. A history of toxic shock syndrome (TSS) is a contraindication for using a cervical cap. TSS is a severe, potentially life-threatening condition often associated with the use of barrier methods like tampons or cervical caps, which can increase the risk of infection.

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A nurse is assisting with the care of a postpartum client who delivered vaginally 8 hr ago. Exhibits Select the 3 findings that require immediate follow-up.

Nursing Test Bank

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A nurse is assisting with the care of a postpartum client who delivered vaginally 8 hr ago.

Exhibits

Select the 3 findings that require immediate follow-up.