A nurse is performing a postpartum assessment 30 minutes after a vaginal delivery.
Which of the following actions indicates that the nurse is performing the assessment correctly?
The nurse performs a sterile vaginal speculum examination.
The nurse measures the fundal height in relation to the symphysis pubis.
The nurse assesses the client's perineum for edema and ecchymoses.
The nurse monitors the client's central venous pressure.
The Correct Answer is C
Choice A rationale
A sterile vaginal speculum examination is not a routine component of the immediate postpartum assessment (first hour after birth). This invasive procedure is typically reserved for evaluating lacerations or the cervix if bleeding is excessive or pathology is suspected, not for a standard 30-minute assessment, which focuses on hemorrhage and recovery.
Choice B rationale
The fundal height is measured in relation to the umbilicus immediately postpartum, not the symphysis pubis. Within the first hour after delivery, the uterine fundus should be firm and located at or near the level of the umbilicus (U/U to U/1, meaning at or one fingerbreadth below the umbilicus), which indicates proper uterine involution and contractility.
Choice C rationale
Assessing the client's perineum for edema (swelling) and ecchymoses (bruising) is a crucial and correct action. Edema and ecchymosis indicate soft tissue trauma from the delivery, increasing the risk for hematoma formation and discomfort, and must be monitored to ensure timely intervention for complications.
Choice D rationale
Monitoring the client's central venous pressure (CVP) is a technique used in critical care settings to assess fluid status and cardiac function. It is not a part of the standard postpartum assessment for a healthy woman after a routine vaginal delivery, which focuses on vital signs, fundus, lochia, and perineum.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D","E"]
Explanation
Choice A rationale
Body tremors are a common neurobehavioral sign of Neonatal Abstinence Syndrome (NAS), reflecting generalized central nervous system (CNS) hyperirritability due to the absence of the maternally supplied opioid. These tremors often manifest as rhythmic, involuntary muscle contractions, exacerbated by external stimuli, and are indicative of the heightened state of arousal and dysregulated autonomic nervous system functioning characteristic of withdrawal.
Choice D rationale
Excessive sneezing is a manifestation of autonomic nervous system dysfunction and hyperreflexia characteristic of NAS. The withdrawal state often causes overreaction to normal environmental stimuli, including tactile and olfactory inputs. This hypersensitivity leads to symptoms like frequent sneezing, yawning, and nasal stuffiness (rhinorrhea), which are non-specific indicators of neurobehavioral stress and autonomic instability.
Choice E rationale
Hyperirritability, defined as an excessive response to stimuli or an inability to be comforted, is a cardinal sign of NAS. It reflects a state of CNS hypersensitivity where the neonate's threshold for stimulation is significantly lowered. The infant exhibits frantic, high-pitched crying, increased wakefulness, and an exaggerated Moro reflex, demonstrating the profound disruption in neurological regulation caused by drug withdrawal.
Choice B rationale
Drowsiness or lethargy is not a typical manifestation of the hyper-excitable state seen in opioid-related NAS; rather, the infant usually exhibits wakefulness and difficulty sleeping. Drowsiness or CNS depression would be more characteristic of maternal overdose, the immediate acute drug effect on the newborn before withdrawal begins, or withdrawal from CNS depressants like barbiturates or alcohol, but not the hyperactivity seen in classic NAS.
Choice C rationale
Excessive appetite is not a characteristic finding in NAS. Paradoxically, infants undergoing withdrawal often exhibit poor feeding and an uncoordinated sucking reflex, sometimes accompanied by vomiting and diarrhea (gastrointestinal hypermotility). This combination leads to failure to thrive and significant weight loss, necessitating supportive and pharmacological management to ensure adequate nutrition and hydration during the withdrawal period.
Correct Answer is B
Explanation
Choice A rationale
Retained placental fragments prevent the uterus from fully contracting effectively, leading to uterine atony and subsequent postpartum hemorrhage. The uterus would typically be palpable as boggy (soft) and potentially enlarged, which directly contradicts the clinical finding of a firm uterus that is 1 cm below the umbilicus, indicating effective fundal contraction.
Choice B rationale
A cervical laceration is a common cause of postpartum hemorrhage when the uterus is firm and well-contracted. Tearing of the cervix during delivery damages blood vessels, resulting in continuous seepage or a steady flow of bright red blood. The firm fundus rules out uterine atony, directing suspicion toward an uncontracted tear in the lower genital tract.
Choice C rationale
Uterine atony is the failure of the myometrium to contract, leaving the blood vessels at the placental site open and bleeding excessively. This condition causes the uterus to be palpated as boggy (soft and poorly contracted) and often elevated, which is contrary to the client's assessment of a firm uterus 1 cm below the umbilicus.
Choice D rationale
A urinary tract infection (UTI) usually presents with symptoms like dysuria, frequency, urgency, or possibly fever and hematuria, not primarily as continuous seepage of blood from the vagina. While a UTI is possible postpartum, the immediate and specific presentation of continuous blood seepage with a firm uterus points to a bleeding issue, not an infection.
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