A nurse is caring for a 32-year-old female client in the postpartum unit who had a cesarean birth due to preeclampsia. The client has been prescribed misoprostol.
Exhibits
The nurse is assessing the client 1 hour later. How should the nurse interpret the findings?
For each finding, click to specify whether the finding is unrelated to the diagnosis, an indication of potential improvement, or an indication of potential worsening condition.
Fundus 2 cm above umbilicus
Blood pressure 90/60 mm Hg
Heart rate 110/min
Continued heavy vaginal bleeding
Client reports feeling dizzy
Cloudy urine
The Correct Answer is {"A":{"answers":"C"},"B":{"answers":"B"},"C":{"answers":"C"},"D":{"answers":"C"},"E":{"answers":"C"},"F":{"answers":"A"}}
• Fundus 2 cm above umbilicus: This could be a sign of potential worsening condition as it might indicate uterine atony, a condition in which the uterus fails to contract after the delivery, leading to continuous bleeding.
• Blood pressure 90/60 mm Hg: This could be an indication of potential improvement as it is within the normal range, and lower than the previous reading which was elevated due to preeclampsia.
• Heart rate 110/min: This could be a sign of potential worsening condition as it is slightly elevated, which could be a response to blood loss.
• Continued heavy vaginal bleeding: This could be a sign of potential worsening condition as it might indicate postpartum hemorrhage.
• Client reports feeling dizzy: This could be a sign of potential worsening condition as it might be due to blood loss leading to decreased perfusion to the brain.
• Cloudy urine: This is unrelated to the diagnosis. It could be due to dehydration or a urinary tract infection, but it’s not directly related to preeclampsia or postpartum hemorrhage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Asking why the adolescent is requesting birth control may come across as judgmental and could discourage open communication.
Choice B rationale
Understanding what the adolescent knows about contraception can help guide the discussion and ensure that she is making an informed decision.
Choice C rationale
Whether or not the partner loves the adolescent is not directly relevant to the decision to use birth control. The focus should be on the adolescent’s reproductive health and autonomy.
Choice D rationale
While it’s important to discuss coercion in sexual relationships, this question could be seen as intrusive or presumptive. It’s more appropriate to provide information about healthy relationships and consent.
Correct Answer is A
Explanation
Choice A rationale
Assessing for edema is an important action for the nurse to take when caring for a client who is 1 hr postpartum and has preeclampsia without severe features. Edema can be a sign of worsening preeclampsia.
Choice B rationale
Administering an IV bolus of lactated Ringer’s is not typically necessary for a client with preeclampsia without severe features.
Choice C rationale
Obtaining a prescription for misoprostol is not relevant in this context. Misoprostol is a medication used to induce labor or treat postpartum hemorrhage, not preeclampsia.
Choice D rationale
Assisting the client with food intake is not directly related to the management of preeclampsia
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