A nurse is collecting data from a client who is 20 hr postpartum following a vaginal delivery. Which of the following findings should the nurse expect?

Positive Homans' sign

Full, firm breasts

Firm fundus at midline

Lochia serosa

Answer and Explanation

The Correct Answer is C

A.   Homans' sign is a test for deep vein thrombosis and is not a normal postpartum finding.
B.   Full, firm breasts typically occur a few days after delivery when milk production begins, not at 20 hours postpartum.
C.   A firm fundus at the midline is an expected finding in the immediate postpartum period, indicating that the uterus is contracting and involuting properly.
D.   Lochia serosa (pinkish-brown discharge) is a normal finding around 3 to 10 days postpartum, but it is not typically present at 20 hours postpartum.

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Correct Answer is A

Explanation

A. Hyporeflexia is a significant adverse effect of magnesium sulfate therapy and can indicate magnesium toxicity. It is essential for the nurse to monitor deep tendon reflexes as part of the assessment when a client is receiving this medication. A decrease in reflexes may warrant immediate intervention and reporting to the provider.
B. Tachypnea is not a common adverse effect of magnesium sulfate; however, if it occurs, it may indicate respiratory distress, which should be assessed further.
C. Polyuria is not a typical adverse effect of magnesium sulfate. In fact, magnesium can lead to decreased urine output in some cases, especially with toxicity.
D. Agitation is also not a typical adverse effect of magnesium sulfate. Clients receiving magnesium sulfate may exhibit sedation rather than agitation.

A. Positive Moro reflex B. Erythema toxicum C. Acrocyanosis D. Elevated bilirubin level

Correct Answer is D

Explanation

A. a positive Moro reflex, is a normal and expected finding in a newborn. It is not a cause for concern.
B. erythema toxicum, is a benign rash that is common in newborns and does not require reporting to the provider.
C. acrocyanosis, is a normal finding in newborns and is not typically a cause for concern.
D. an elevated bilirubin level, can indicate jaundice, which may require treatment or further evaluation. This finding should be reported to the provider for appropriate management.

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A nurse is collecting data from a client who is 20 hr postpartum following a vaginal delivery. Which of the following findings should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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