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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 A

Explanation

A. Yogurt is an excellent source of calcium and is recommended to increase calcium intake during pregnancy. Adequate calcium is important for fetal bone development and maternal health.
B. Peanut butter is a good source of protein and healthy fats but is not high in calcium. It does not effectively address a low calcium level compared to dairy products or fortified foods.
C. Long-grain rice is a staple food but does not provide significant amounts of calcium. It is a carbohydrate source rather than a calcium-rich food.
D. Avocados are nutritious and provide healthy fats, but they are not significant sources of calcium. To correct a calcium deficiency, foods rich in calcium are needed.

A. "Take 650 milligrams of aspirin for leg discomfort." B. "You should not take oral contraceptives while taking this medication." C. "You will be able to stop taking this medication in 2 weeks." D. "Use a disposable razor for shaving while taking this medication."

Correct Answer is B

Explanation

- Rationale for A: Aspirin is an antiplatelet agent and can increase the risk of bleeding, especially when combined with warfarin, an anticoagulant. Therefore, taking aspirin for leg discomfort is not recommended as it can exacerbate bleeding risks.
- Rationale for B: Oral contraceptives can interfere with the effectiveness of warfarin and increase the risk of thrombotic events. Women taking warfarin, especially in the postpartum period, should avoid oral contraceptives due to the potential for increased blood clotting.
- Rationale for C: The duration of warfarin therapy for deep-vein thrombosis is typically longer than 2 weeks. It is determined by the physician based on the extent of the clot and the patient's response to the medication.
- Rationale for D: Using a disposable razor can help minimize the risk of cuts and subsequent bleeding, which is a concern when taking anticoagulants like warfarin. It is a safer alternative to other shaving methods that may cause skin abrasions.

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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.

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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.