A nurse is conducting an assessment on a client who is 4 hours postpartum following a vaginal delivery. Which of the following findings should the nurse prioritize?
Fundus at the level of the umbilicus
Saturated perineal pad in 30 minutes
Approximated edges of episiotomy
Deep tendon reflexes 4+
The Correct Answer is B
Choice A rationale
While the fundus at the level of the umbilicus is a normal finding for a woman who is 4 hours postpartum, it is not the priority in this case. The fundus, which is the top part of the uterus, typically descends at a rate of approximately one fingerbreadth (or one cm) per day, and by the 12th postpartum day, it should no longer be palpable.
Choice B rationale
A saturated perineal pad in 30 minutes is a sign of excessive bleeding, also known as postpartum hemorrhage. This is a serious condition that can lead to shock and other complications if not treated promptly. Therefore, this finding should be prioritized by the nurse.
Choice C rationale
Approximated edges of an episiotomy are a normal finding in the postpartum period. An episiotomy is a surgical incision made in the perineum to enlarge the vaginal opening for delivery. After delivery, the episiotomy is sutured and should heal without complications with proper care. However, this is not the priority finding in this scenario.
Choice D rationale
Deep tendon reflexes 4+ could be a sign of preeclampsia, a pregnancy complication characterized by high blood pressure and signs of damage to another organ system, often the liver and kidneys. However, since the client is already 4 hours postpartum, this is less likely to be the priority.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Obtaining rectal temperatures is not recommended for newborns with spinal bifida. This is because the rectal route can introduce bacteria into the body, which can lead to infection.
Additionally, the rectal route may not provide an accurate temperature reading for these newborns.
Choice B rationale
Covering the lesion with a dry dressing is not recommended for newborns with spinal bifida. The lesion should be kept moist to prevent drying and cracking, which can lead to infection.
Choice C rationale
Applying snug clean diapers is not recommended for newborns with spinal bifida. This is because the pressure from the diaper can damage the exposed nerves and tissues in the lesion area.
Choice D rationale
Placing the newborn in the prone position is recommended for newborns with spinal bifida. This position helps to minimize pressure on the lesion and reduces the risk of trauma and infection.
Correct Answer is A
Explanation
Choice A rationale
This statement is correct. It is recommended that newborns be breastfed 8 to 12 times per day, which is about every 2 to 3 hours.
Choice B rationale
Supplementing with formula after breastfeeding is not typically recommended unless there is a medical reason. Supplementing can interfere with the supply and demand process that increases milk supply.
Choice C rationale
Using plastic-lined breast pads can trap moisture and exacerbate sore nipples. It is recommended to use 100% cotton breast pads and to change them frequently to keep the nipples dry.
Choice D rationale
While staying hydrated is important for overall health, there is no definitive evidence that drinking more water will increase milk supply. However, some mothers find that staying well- hydrated helps with their overall comfort and well-being during breastfeeding.
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