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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. An abdominal sonogram is not used to diagnose or manage mastitis. Mastitis is typically evaluated and managed through clinical examination and does not require imaging of the abdomen.
B. Limiting fluid intake is not recommended for managing mastitis. Adequate hydration is important to support the body's healing processes and help with milk production.
C. A bra should be supportive, not loose-fitting, to help manage mastitis. A well-fitting, supportive bra can help alleviate discomfort and provide proper support during breastfeeding.
D. Continuing to breastfeed or pumping milk is encouraged to help resolve mastitis. Frequent milk removal can help clear the infection and prevent complications, such as an abscess.

A. "I should expect to have burning when I urinate during the third trimester." B. "I may have an infection if I develop a dark line in the middle of my abdomen." C. "I may develop discoloration on my cheeks from hormonal changes." D. "I should expect my fingers and face to be swollen."

Correct Answer is C

Explanation

A. Experiencing burning during urination is not a normal physiological change during pregnancy and could indicate a urinary tract infection. It is important to report this symptom to a healthcare provider for evaluation and appropriate management.
B. The dark line in the middle of the abdomen, known as the linea nigra, is a common and normal physiological change during pregnancy due to hormonal effects, not an indication of infection. This statement reflects a misunderstanding of normal pregnancy changes.
C. Developing discoloration on the cheeks, often referred to as the "mask of pregnancy" or melasma, is a common and expected physiological change due to hormonal fluctuations. This statement shows that the client understands a normal aspect of pregnancy.
D. Swelling of the fingers and face is not a typical or expected change during pregnancy and could indicate a serious condition such as preeclampsia. While mild swelling of the ankles and feet can be normal, swelling in these areas should be evaluated by a healthcare provider.

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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

Naxlex Comprehensive Predictor Exams

A nurse is contributing to the plan of care for a client who is postpartum and has mastitis. Which of the following actions should the nurse plan to take?

Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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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.