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.
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Correct Answer is A
Explanation
Choice A rationale
An ectopic pregnancy, where the fertilized egg attaches outside the uterus, often presents with unilateral, cramp-like abdominal pain. This is because as the fertilized egg grows in an area where it cannot survive, it can cause irritation and bleeding, leading to pain. This pain is often one-sided or unilateral and can vary from mild to severe. It’s one of the key symptoms that can suggest an ectopic pregnancy in the early weeks of gestation.
Choice B rationale
Severe nausea and vomiting are not typically the primary symptoms associated with an ectopic pregnancy. While nausea can be a symptom of early pregnancy, severe nausea and vomiting alone without other symptoms would not necessarily indicate an ectopic pregnancy.
Choice C rationale
Uterine enlargement greater than expected for gestational age is not a symptom of an ectopic pregnancy. In fact, because the pregnancy is not in the uterus, the size of the uterus may not correlate with the expected size at the given gestational age.
Choice D rationale
While vaginal bleeding can occur in an ectopic pregnancy, it is not typically a large amount. The bleeding is often lighter than normal menstrual bleeding and may be associated with a change in color of the vaginal discharge.
Correct Answer is B
Explanation
Choice A rationale
While it’s true that a newborn’s stools will transition in color, it typically takes a few days longer than one or two. Initially, the stools are a greenish-black color known as meconium. Over the next few days, as the baby begins digesting breast milk or formula, the stools will gradually transition to a yellow color.
Choice B rationale
This statement is correct. After childbirth, the breasts undergo a process known as engorgement when they start to produce milk. This can cause the breasts to become harder, warmer, and more tender. This is a normal part of the postpartum period and is a sign that the body is preparing to feed the baby.
Choice C rationale
While it’s true that abdominal discomfort generally decreases over time after childbirth, it’s important to note that the rate of decrease can vary greatly among individuals. Factors such as the type of delivery (vaginal or cesarean), individual pain tolerance, and the presence of any complications can all influence the rate of decrease in abdominal discomfort.
Choice D rationale
While it’s true that many women do feel more energetic as their bodies recover from childbirth, this is not always the case. Factors such as sleep deprivation, hormonal changes, and the physical demands of caring for a newborn can all contribute to feelings of fatigue and exhaustion. Therefore, while some women may feel more energetic, others may continue to feel tired for several weeks or even months after giving birth.
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