A nurse is collecting data from a client who is 18 hr postpartum.Which of the following findings require the nurse to intervene?

Fundus located to right of umbilicus.

Temperature 37.8° C (100° F).

Deep tendon reflexes 2+.

Moderate amount of lochia rubra.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Fundus located to the right of the umbilicus requires intervention. This can indicate a full bladder, which can inhibit uterine contraction and increase the risk of postpartum hemorrhage.

Choice B rationale

A temperature of 37.8° C (100° F) is a common finding postpartum and usually does not require intervention unless it is accompanied by other signs of infection.

Choice C rationale

Deep tendon reflexes 2+ is a normal finding and does not require intervention. It indicates normal neuromuscular function.

Choice D rationale

A moderate amount of lochia rubra is expected postpartum and does not require intervention unless it is excessive or associated with other abnormal symptoms.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

The correct answer is Choice C.

Choice A rationale: Deep-vein thrombosis is not a contraindication for using a diaphragm. The diaphragm does not affect blood clotting mechanisms.

Choice B rationale: Tobacco use is a risk factor for cardiovascular disease but is not a contraindication for diaphragm use.

Choice C rationale: Recurrent urinary tract infections are a contraindication for diaphragm use. The diaphragm can increase the risk of urinary tract infections due to its placement and the need for spermicide, which can disrupt the natural flora of the vagina.

Choice D rationale: A history of positive group B streptococcus B-hemolytic is not a contraindication for diaphragm use. Group B strep colonization is managed with antibiotics during labor, not by contraceptive choice.

A. Encourage frequent ambulation B. Ensure the client maintains a supine position while in bed C. Check FHR every 30 min D. Perform a Nitrazine test E. Prepare the client for catheterization F. Obtain CBC blood sample G. Check the client's temperature every hour

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	✔

View Question and Answer

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

A nurse is collecting data from a client who is 18 hr postpartum.Which of the following findings require the nurse to intervene?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a provider's office is reviewing the medical record of a client who is requesting a diaphragm.Which of the following findings in the client's history should the nurse identify as a contraindication for this type of contraception?

Correct Answer is C

Explanation

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 caring for a client who is at 39 weeks of gestation and is in active labor.The nurse notes maternal exposure to rubella during pregnancy.After delivery, the nurse should monitor the newborn for which of the following conditions?

A nurse is reinforcing teaching with a client who is at 38 weeks of gestation and has a positive group B streptococcus B-hemolytic screening.Which of the following medications should the nurse discuss as the prophylaxis treatment during labor for this client?

A nurse is assisting with the care of a client who is in active labor.The fetal monitor tracing shows late decelerations.Which of the following actions should the nurse take first?

A nurse is reinforcing teaching about crib safety with a group of prenatal clients.Which of the following information should the nurse include in the teaching?

A nurse is reinforcing teaching with a client who is undergoing amniotic fluid assessment for the lecithin/sphingomyelin ratio.Which of the following client statements indicates an understanding of the teaching?

A nurse is reinforcing teaching about breastfeeding with the mother of a newborn.Which of the following instructions should the nurse include?

A nurse is caring for a client who is postpartum and has inverted nipples.Which of the following actions should the nurse take?

A nurse is assisting in the care of a client who is in labor and requires intermittent fetal monitoring.Which of the following actions should the nurse take?