A nurse is caring for a 32-year-old female client who is 2 days postpartum in the postpartum unit.

Exhibits

For each potential client finding, click to specify if the finding is expected or unexpected.

White blood cell count

Blood clot size

Uterine findings

Lochia findings

Calf findings

Blood pressure

Answer and Explanation

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

White blood cell count: Expected—mild leukocytosis is normal postpartum due to physiological stress.
Blood clot size: Expected—small clots, like a pea-sized clot, are common and not concerning unless excessive bleeding occurs.
Uterine findings: Expected—firm and midline uterus indicating effective involution.
Lochia findings: Expected—progressing normally without signs of infection (no foul odor).
Calf findings: Expected—a single varicose vein without tenderness or swelling is not concerning.
Blood pressure: Expected—within normal postpartum range.

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Correct Answer is D

Explanation

Choice A rationale

Preparing to administer a prescribed oxytocic preparation is a possible intervention for postpartum hemorrhage, but the immediate first step should be to assess the uterus, the most common source of early postpartum bleeding.

Choice B rationale

Assessing the client's blood pressure is important in evaluating the extent of blood loss, but it is not the initial action to take. Addressing the likely cause of the bleeding should precede further assessment of vital signs.

Choice C rationale

Assessing the bladder for distention is important as a full bladder can displace the uterus and interfere with its contraction, potentially contributing to bleeding. However, directly addressing the uterine tone is the immediate first step.

Choice D rationale

Massaging the client's fundus is the priority action because uterine atony, a soft and non-contracted uterus, is the most frequent cause of early postpartum hemorrhage. Stimulating the uterus to contract by massage helps to compress the blood vessels at the placental site and decrease bleeding. .

A. Changes in the cervix. B. Station of the presenting part. C. Rupture of the membranes. D. Pattern of contractions.

Correct Answer is A

Explanation

Choice A rationale

True labor is characterized by progressive cervical changes, including effacement (thinning) and dilation (opening) of the cervix. These changes are the most definitive signs that a woman is in true labor, as contractions can sometimes be Braxton Hicks contractions, which do not cause cervical change.

Choice B rationale

The station of the presenting part (how far down the baby's head is in the pelvis) can change during true labor as the baby descends. However, a single assessment of station does not definitively indicate true labor, as the baby may have been in a lower position prior to the onset of labor. Cervical changes are a more reliable indicator.

Choice C rationale

Rupture of the membranes (water breaking) can occur before or during true labor, but it is not always the first sign of labor. Some women experience contractions for a period before their membranes rupture, and some may not have their membranes rupture until late in labor or require artificial rupture. Therefore, it is not the most definitive sign of true labor.

Choice D rationale

A pattern of regular contractions that increase in frequency, duration, and intensity is a strong indication of true labor. However, some women may experience irregular contractions (Braxton Hicks) that can be mistaken for early labor. The key differentiator is whether these contractions are causing cervical change, making cervical assessment the most definitive sign.

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A nurse is caring for a 32-year-old female client who is 2 days postpartum in the postpartum unit. Exhibits For each potential client finding, click to specify if the finding is expected or unexpected.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is 1 hour postpartum following a vaginal birth.The client has saturated a perineal pad within 10 minutes.Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

A nurse is caring for a client who is a primigravida, at term, and having contractions but is stating that she is "not really sure if she is in labor or not.”. Which of the following should the nurse recognize as a sign of true labor?

Correct Answer is A

Explanation

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A nurse is caring for a 32-year-old female client who is 2 days postpartum in the postpartum unit. Exhibits For each potential client finding, click to specify if the finding is expected or unexpected.

The nurse is assessing the lochia on a 1-day postpartum patient.The nurse notes that the lochia is red and has a foul-smelling odor.The nurse determines that this assessment finding:

A nurse is caring for a client who is being admitted to the labor and delivery unit.Client reports mild abdominal pain and light vaginal bleeding.Reports last menstrual period was 11 weeks ago.

A nurse is caring for a 32-year-old female client who is 2 days postpartum in the postpartum unit.

Exhibits

For each potential client finding, click to specify if the finding is expected or unexpected.