A nurse is assisting with the care of a postpartum client who delivered vaginally 8 hr ago.
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+
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Uterine contractions lasting 30 to 45 seconds
Rationale: Uterine contractions lasting 30 to 45 seconds are within the expected range for the latent phase of labor. This duration indicates that contractions are occurring but are not too frequent or too prolonged, which is typical for this stage of labor.
B. Uterine contractions every 6 min
Rationale: Contractions every 6 minutes are also typical for the latent phase of labor, where contractions are still becoming more frequent as labor progresses. This frequency does not suggest fetal distress or a significant risk to the fetus.
C. Recurrent variable deceleration of the FHR
Rationale: Recurrent variable decelerations in fetal heart rate (FHR) indicate that the fetus might be experiencing umbilical cord compression. This finding suggests a risk to the fetus, as it can be associated with reduced oxygenation and may require intervention to manage labor and optimize fetal well-being.
D. Moderate variability of the FHR
Rationale: Moderate variability in FHR is an indication of a well-oxygenated fetus and a healthy autonomic nervous system. This is a reassuring sign of fetal well-being rather than a risk.
Correct Answer is D
Explanation
A. Increasing the frequency of feedings from the affected nipple can worsen soreness. It’s important to address the underlying cause of soreness, which may involve evaluating latch technique or positioning rather than increasing feeding frequency.
B. Vitamin E oil is not recommended for sore nipples as it can cause irritation. Proper care involves managing latch and positioning, and sometimes using a lanolin cream rather than oils or other substances.
C. Washing the nipple with soap and water before each feeding can remove natural oils and lead to further irritation. The nipple should be gently cleaned with water, if necessary, and kept clean without over-washing.
D. Exposing the affected nipple to the air between feedings helps with healing and reduces moisture, which can exacerbate soreness. Allowing the nipple to air-dry can promote healing and reduce discomfort.
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