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+

Answer and Explanation

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

The correct answer is Choice A........ Therefore, it poses the greatest risk to a newborn who is 30 minutes old...... However, it is less immediately life-threatening compared to meconium aspiration syndrome...... However, it is less immediately life-threatening compared to meconium aspiration syndrome. . Glucose is the main source of fuel for the brain and the body. In a newborn baby, low blood sugar can happen for many reasons. . However, it is less immediately life-threatening compared to meconium aspiration syndrome.

Choice E rationale

Jaundice due to color of amniotic fluid is not a recognized medical condition........................... However, it is less immediately life-threatening compared to meconium aspiration syndrome.

A. Evaluate the firmness of the uterus. B. Administer oxytocin infusion. C. Obtain a type and crossmatch. D. Initiate oxygen therapy by nonrebreather mask.

Correct Answer is A

Explanation

Choice A rationale

If a nurse notes that a client’s blood pressure is 60/50 mm Hg two hours after giving birth, the first action should be to evaluate the firmness of the uterus. This is because a soft or “boggy” uterus could indicate uterine atony, a condition where the uterus fails to contract after delivery, leading to excessive bleeding and a drop in blood pressure.

Choice B rationale

Administering oxytocin infusion can help stimulate uterine contractions and control postpartum bleeding. However, it is not the first action to take. The nurse should first assess the firmness of the uterus.

Choice C rationale

Obtaining a type and crossmatch is important if a blood transfusion is required. However, this is not the first action. The nurse should first assess the firmness of the uterus.

Choice D rationale

Initiating oxygen therapy can help ensure adequate oxygen supply to the tissues, but it is not the first action. The nurse should first assess the firmness of the uterus.

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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?

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a newborn who is 30 minutes old. After reviewing the information in the newborn’s medical record, which of the following complications should the nurse identify as posing the greatest risk?

Correct Answer is A

Explanation

Choice E rationale

A nurse is caring for a client who gave birth 2 hours ago. The nurse notes that the client’s blood pressure is 60/50 mm Hg. What should be the nurse’s first action?

Correct Answer is A

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

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