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A nurse is assisting with the care of a postpartum female client who delivered vaginally 8 hours ago in the maternity unit.

Exhibits

Select the 3 findings that require immediate follow-up.

A.

Deep tendon reflexes 1+

B.

Lateral deviation of the uterus

C.

Blood pressure 136/86 mm Hg

D.

Pain rating of 3 on a scale of 0 to 10

E.

Breasts soft

F.

Uterine tone soft

G.

Large amount of lochia rubra

H.

Peripheral edema 2+ in bilateral lower extremities

Answer and Explanation

Correct Answer : B,F,G

Choice A rationale:

Deep tendon reflexes of 1+ are considered normal for a postpartum client and do not typically require immediate follow-up. They indicate slight but definite muscle contraction with reinforcement.

 

Choice B rationale:

Lateral deviation of the uterus can indicate bladder distension, which can interfere with uterine contraction and increase the risk of postpartum hemorrhage. Immediate follow-up is necessary to address this issue.

 

Choice C rationale:

A blood pressure of 136/86 mm Hg is within the normal range for a postpartum client and does not require immediate follow-up unless there are other symptoms of preeclampsia or hypertension.

 

Choice D rationale:

A pain rating of 3 on a scale of 0 to 10 is mild and is expected in the postpartum period. It does not require immediate follow-up unless the pain is severe or unrelieved.

 

Choice E rationale:

Soft breasts in the immediate postpartum period are normal as milk production has not yet fully begun. This does not require immediate follow-up.

 

Choice F rationale:

A soft uterine tone indicates uterine atony, which can lead to postpartum hemorrhage. This requires immediate follow-up and intervention to ensure the uterus is contracting properly.

 

Choice G rationale:

A large amount of lochia rubra can be a sign of postpartum hemorrhage. Immediate follow-up is necessary to assess and manage bleeding.

 

Choice H rationale:

Peripheral edema of 2+ in the bilateral lower extremities is common in postpartum clients due to fluid shifts and does not typically require immediate follow-up unless accompanied by other concerning symptoms.


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Related Questions

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"C"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"A"},"G":{"answers":"A"}}

Explanation

  1. Encourage frequent ambulation - Anticipated
    • Ambulation can help progress labor and is generally encouraged if there are no contraindications.
  2. Ensure the client maintains a supine position while in bed - Contraindicated
    • Supine positioning can decrease uteroplacental blood flow and is generally not recommended during labor.
  3. Check FHR every 30 min - Anticipated
    • Regular monitoring of the fetal heart rate is essential to assess fetal well-being during labor.
  4. Perform a Nitrazine test - Anticipated
    • Since the client reports a gush of fluid, a Nitrazine test can help confirm whether the membranes have ruptured.
  5. Prepare the client for catheterization - Nonessential
    • The client has voided recently and doesn’t indicate difficulty, making catheterization unnecessary at this stage.
  6. Obtain CBC blood sample - Anticipated
    • A CBC can provide important information about the client's health status and identify any potential issues, like infection or anemia.
  7. Check the client's temperature every hour - Anticipated
    • Regularly monitoring temperature can help detect signs of infection, which is particularly important if the membranes have ruptured.

Intervention

Anticipated

Nonessential

Contraindicated

Encourage frequent ambulation

✔

Ensure the client maintains a supine position while in bed

✔

Check FHR every 30 min

✔

Perform a Nitrazine test

✔

Prepare the client for catheterization

✔

Obtain CBC blood sample

✔

Check the client's temperature every hour

✔

Correct Answer is D

Explanation

Choice A rationale

Instructing the client to apply anesthetic spray to the site three to four times a day is incorrect. While anesthetic sprays can help with pain relief, it's more important to manage swelling and discomfort with a combination of methods, including ice packs and perineal care.

Choice B rationale

Encouraging the client to change perineal pads at least three times a day is insufficient. Pads should be changed more frequently to maintain hygiene and prevent infection.

Choice C rationale

Assisting the client to fill the squeeze bottle with cold water to perform perineal care is incorrect. While perineal care is important, cold water is not typically recommended as it may not provide comfort and might even cause discomfort.

Choice D rationale

Alternating warm and ice packs to the site every 2 hours for the first 24 hours postpartum is correct. This method helps manage pain and swelling effectively, promoting healing and comfort for the client.

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