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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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Free Nursing Study Resources

Correct Answer is C,E,A,B,D

Explanation

1. Wrap a warm, moist cloth around the heel to dilate the blood vessels, which makes it easier to obtain the blood sample.

2. Cleanse the heel with an antiseptic to reduce the risk of infection at the puncture site.

3. Puncture the heel and collect the blood, ensuring that the sample is adequate for the test.

4. Apply pressure with a dry gauze pad to stop the bleeding from the puncture site.

5. Cover the heel with an adhesive bandage to protect the area and minimize the risk of infection.

Correct Answer is []

Explanation

- Potential Condition: Hyperemesis Gravidarum

Actions to take

Insert a peripheral venous access device:
Monitor and manage electrolyte values:

Parameters to monitor

Electrolyte values:
Urine ketones:

Rationale

- Potential Condition: Hyperemesis Gravidarum

- This condition is characterized by severe nausea and vomiting, leading to dehydration and nutrient loss, which can affect both the mother and fetus.

- Actions to Take:

1. Insert a peripheral venous access device:

- This will allow for the administration of IV fluids and medications to treat dehydration and correct electrolyte imbalances.

2. Monitor and manage electrolyte values:

- Given the client's low potassium levels, it's crucial to monitor and manage electrolytes to prevent complications.

- Parameters to Monitor:

1. Electrolyte values:

- Monitoring electrolyte levels is essential to ensure they are within normal ranges and to adjust IV fluid composition as needed.

2. Urine ketones:

- Positive urine ketones indicate that the body is using fat for energy due to inadequate glucose utilization, which is common in Hyperemesis Gravidarum. Monitoring will help assess the effectiveness of treatment and nutritional status.

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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

1. A nurse is obtaining a capillary blood sample from a newborn for phenylketonuria testing. Identify the sequence of steps the nurse should follow. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Correct Answer is C,E,A,B,D

Explanation

Correct Answer is []

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.