A nurse is caring for a 28-year-old female client in the fourth stage of labor after a vaginal delivery in the labor and delivery unit.
Which of the following assessment findings require follow-up? Select All That Apply.
Temperature
Fundal tone
Lochia
Respiratory rate
White blood cell count
Blood pressure
Correct Answer : A,B,C,F
Choice A rationale:
A postpartum temperature of 100.4°F (38.0°C) or higher may indicate an infection. Infections can occur after delivery, particularly if there was a manual extraction of the placenta, as in this case. Close monitoring and further assessment are necessary to ensure the client does not develop sepsis or other complications.
Choice B rationale:
Fundal tone should be firm and well-contracted to prevent excessive bleeding postpartum. A boggy, midline fundus suggests that the uterus is not contracting effectively, increasing the risk for postpartum hemorrhage. This requires immediate attention and intervention to ensure adequate uterine tone and control bleeding.
Choice C rationale:
Lochia should be monitored for quantity, color, and the presence of clots. Heavy lochia with small clots indicates that the client may be experiencing postpartum hemorrhage, which is a significant concern. This can be related to uterine atony, retained placental fragments, or coagulopathies and warrants prompt evaluation and intervention.
Choice D rationale:
A respiratory rate of 17/min is within the normal adult range (12-20/min) and does not require follow-up. There are no signs of respiratory distress or abnormalities in this case, indicating that the client's respiratory status is stable and does not necessitate further evaluation.
Choice E rationale:
A white blood cell count of 12,000/mm³ is within the expected range for postpartum women, where normal values can be elevated due to physiological stress and inflammation from delivery. This level does not indicate infection or pathology and does not require follow-up in the context provided.
Choice F rationale:
Blood pressure of 144/92 mmHg is elevated and concerning, particularly in a postpartum client with a history of chronic hypertension and gestational diabetes. This could signal postpartum preeclampsia or other hypertensive disorders, requiring careful monitoring and management to prevent complications like seizures, stroke, or organ damage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Sneezing is a reflex action to clear the nasal passages and is not a feeding cue. It does not indicate hunger but is more likely related to environmental irritants or the baby adjusting to breathing air.
Choice B rationale
Moving legs in a bicycle motion is a common newborn reflex that is associated with general activity or discomfort, rather than a specific signal of hunger. This movement is typically seen during periods of wakefulness or while the baby is trying to soothe themselves.
Choice C rationale
Putting their hand to their mouth is a well-recognized hunger cue in newborns. This behavior often precedes crying and indicates that the baby is ready to feed. It's a self-soothing mechanism that also signals hunger.
Choice D rationale
Extending both arms to the side of their body is more related to the Moro reflex, which is a startle reflex in response to a sudden movement or noise. It is not associated with feeding cues or hunger.
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}
Explanation
Given the provided information, here is the completion of the sentence using the options:
The newborn most likely has Brachial plexus injury as evidenced by Asymmetrical Moro reflex.
This conclusion is drawn from the observation that the newborn does not move the left arm during the Moro reflex, which is indicative of a possible brachial plexus injury. This type of injury can occur during childbirth, especially in cases involving shoulder dystocia and vacuum-assisted delivery.
The reason for diagnosing the newborn with a brachial plexus injury is based on the observation that the newborn does not move the left arm during the Moro reflex. The Moro reflex, also known as the startle reflex, is a normal response in newborns where they spread out their arms and then bring them back towards the body when they feel a sudden loss of support. In this case, the newborn is only moving one arm, which suggests that there might be an injury to the nerves that control movement in the affected arm.
Brachial plexus injuries often occur during difficult births, such as those involving shoulder dystocia and vacuum-assisted deliveries. These types of injuries can lead to weakness or paralysis of the affected arm. Given the details of the newborn's birth and the absence of movement in the left arm during the Moro reflex, a brachial plexus injury is the most likely condition.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.