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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.

Deep tendon reflexes 1+

Lateral deviation of the uterus

Blood pressure 136/86 mm Hg

Pain rating of 3 on a scale of 0 to 10

Breasts soft

Uterine tone soft

Large amount of lochia rubra

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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Free Nursing Study Resources

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

Encourage frequent ambulation - Anticipated
- Ambulation can help progress labor and is generally encouraged if there are no contraindications.
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.
Check FHR every 30 min - Anticipated
- Regular monitoring of the fetal heart rate is essential to assess fetal well-being during labor.
Perform a Nitrazine test - Anticipated
- Since the client reports a gush of fluid, a Nitrazine test can help confirm whether the membranes have ruptured.
Prepare the client for catheterization - Nonessential
- The client has voided recently and doesn’t indicate difficulty, making catheterization unnecessary at this stage.
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.
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	✔

A. I should breastfeed my baby at least six times per day. B. I should keep my baby on a strict breastfeeding schedule. C. I should feed my baby for 30 minutes during each feeding. D. I should hold my baby just below the level of my breast.

Correct Answer is C

Explanation

Choice A rationale

Breastfeeding at least six times per day is too infrequent for a newborn. Newborns typically need to feed more frequently, approximately 8-12 times in 24 hours, to establish a good milk supply and ensure adequate nutrition.

Choice B rationale

Keeping a baby on a strict breastfeeding schedule is not recommended. Feeding should be on demand, based on the baby's hunger cues, to promote effective breastfeeding and milk production.

Choice C rationale

Feeding the baby for 30 minutes during each feeding is correct. This duration allows adequate time for the baby to receive both foremilk and hindmilk, which is essential for nutrition and satiety.

Choice D rationale

Holding the baby just below the level of the breast is incorrect. The baby should be held at breast level to facilitate proper latch and comfortable feeding for both mother and baby. .

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

A nurse is reinforcing discharge teaching about breastfeeding with a client.Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is C

Explanation

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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.