A nurse is caring for a client who is 2 days postpartum.
The client is a Gravida 4 Para 3 who had a forceps-assisted birth with epidural anesthesia at 40 weeks of gestation. She had a second degree mediolateral perineal laceration with repair, and the placenta was manually extracted.
The estimated blood loss was 600 mL. Complete the diagram by dragging from the choices below to specify what condition the client is experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client’s progress.

Apply ice packs to the perineal area.

Monitor for signs of postpartum seizures.

Monitor for signs of strained perineum.

Administer prescribed medications.

Answer and Explanation

Correct Answer : A,C

A nurse is caring for a client who is 2 days postpartum.
The client is a Gravida 4 Para 3 who had a forceps-assisted birth with epidural anesthesia at 40 weeks of gestation. She had a second degree mediolateral perineal laceration with repair, and the placenta was manually extracted.
The estimated blood loss was 600 mL. Complete the diagram by dragging from the choices below to specify what condition the client is experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client’s progress.

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Correct Answer is B

Explanation

Choice A rationale
While the anterior fontanel being soft and level is an important observation in a newborn, it is not typically used as part of a gestational age assessment.
Choice B rationale
The presence of plantar creases covering 3 of the sole is a typical finding in a full-term newborn and is used as part of a gestational age assessment.
Choice C rationale
Acrocyanosis, or bluish discoloration of the hands and feet, is a common finding in newborns, especially shortly after birth. However, it is not typically used as part of a gestational age assessment.
Choice D rationale
Vernix caseosa in the inguinal creases can be a sign of a preterm newborn, as vernix caseosa is typically present in larger amounts in preterm newborns. However, it is not typically used as part of a gestational age assessment.

A. Notify the client’s provider. B. Document the findings and continue to monitor the client. C. Increase the frequency of fundal massage. D. Encourage the client to empty her bladder.

Correct Answer is B

Explanation

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following observations should be recorded as part of a newborn gestational age assessment?

Correct Answer is B

Explanation

What action should a nurse take when caring for a client who is 1 hr postpartum and observes a large amount of lochia rubra and several small clots on the client’s perineal pad, with the fundus midline and firm at the umbilicus?

Correct Answer is B

Explanation

What Apgar score should a nurse document for a newborn with a pink trunk and head, bluish hands and feet, flexed extremities 5 min after delivery, a weak and slow cry, a heart rate of 130/min, and cries in response to suctioning?

A nurse in a provider’s office is caring for a client who is at 34 weeks of gestation and at risk for placental abruption. Which of the following is the most common risk factor for abruption?

A nurse is caring for a client who experienced a vaginal delivery 12 hr ago. When palpating the client’s abdomen, at which of the following positions should the nurse expect to find the uterine fundus?

A nurse is caring for a client who is 42 weeks of gestation. Exhibits Based on the updated assessment findings, which of the following actions should the nurse plan to take? Click to specify whether the nurse’s planned actions are anticipated, nonessential, or contraindicated.

A nurse admits a woman who is at 38 weeks of gestation and in early labor with ruptured membranes. The nurse determines that the client’s oral temperature is 38.9°C (102°F). Besides notifying the provider, which of the following is an appropriate nursing action?

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A nurse is attending to a client 2 hours after a spontaneous vaginal birth and the client has saturated two perineal pads with blood within a 30-minute period. What should be the priority nursing intervention at this time?