A nurse is caring for a group of clients on a postpartum unit.
Which of the following findings should be reported to the RN immediately?
A client who has preeclampsia has 2+ patellar reflex and 2+ proteinuria
A client who is at 24 weeks of gestation
A client who has preeclampsia
A client who has a heart rate of 100/min
The Correct Answer is A
Choice A rationale:
2+ patellar reflex: A hyperactive patellar reflex (also known as a knee-jerk reflex) is a sign of hyperreflexia, which can be a neurological symptom of preeclampsia. Hyperreflexia results from heightened nerve excitability and can manifest as exaggerated reflexes. In preeclampsia, it stems from central nervous system irritability due to cerebral edema or other neurological disturbances.
2+ proteinuria: Proteinuria, defined as the presence of excessive protein in the urine, is a hallmark sign of preeclampsia. It indicates glomerular damage in the kidneys, leading to protein leakage into the urine. The degree of proteinuria is graded on a scale of 1+ to 4+, with 2+ representing a significant level that warrants immediate attention.
Choice B rationale:
24 weeks of gestation: While 24 weeks of gestation is considered early preterm birth, it is not inherently a finding that requires immediate reporting to the RN in the context of postpartum care. The focus on the postpartum unit is primarily on the health of the mother and newborn after delivery, rather than managing ongoing pregnancies.
Choice C rationale:
Preeclampsia: While preeclampsia is a serious condition that necessitates close monitoring and management, the mere diagnosis of preeclampsia without additional concerning findings does not automatically require immediate reporting to the RN. It's essential to assess for specific signs and symptoms that indicate worsening or complications of preeclampsia, such as those mentioned in Choice A.
Choice D rationale:
Heart rate of 100/min: A heart rate of 100 beats per minute is within the normal range for adults, even postpartum. Mild tachycardia (increased heart rate) can be a physiological response to various factors such as pain, anxiety, or exertion, and it does not always signify a serious problem. However, if the heart rate is persistently elevated or accompanied by other concerning symptoms, it would warrant further evaluation.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Placing a soft pillow under the client's buttocks is not recommended for episiotomy pain relief. It can actually increase pain by
placing pressure on the perineum and reducing blood flow to the area.
Additionally, it can separate the buttocks, further straining the incision site and hindering healing.
It's crucial to prioritize interventions that promote circulation and reduce pressure on the perineum to facilitate healing and
pain management.
Choice C rationale:
Positioning a heating lamp toward the episiotomy is not appropriate within the first 24 hours following delivery.
Heat application during this early stage can increase inflammation and swelling, potentially worsening pain and delaying
healing.
It's essential to allow the initial inflammatory phase of wound healing to subside before introducing heat therapy.
Choice D rationale:
Preparing a warm sitz bath is a helpful intervention for episiotomy pain, but it's generally recommended after the first 24
hours.
During the initial phase of healing, warm water can increase blood flow to the area, potentially leading to increased swelling
and discomfort.
It's often more beneficial to focus on cooling measures within the first 24 hours to reduce inflammation and promote comfort.
Choice B rationale:
Applying an ice pack to the perineum is the most appropriate action for the nurse to take in this scenario.
Cold therapy effectively reduces inflammation, swelling, and pain by constricting blood vessels and slowing nerve conduction.
It's a non-invasive and readily available intervention that can significantly improve comfort and promote healing in the early
stages of episiotomy recovery.
Key points:
Ice packs are generally recommended for the first 24 hours following an episiotomy to reduce pain and inflammation.
Heat therapy, such as sitz baths or heating lamps, can be helpful after the initial 24-hour period to promote circulation and
healing.
Pillows or cushions under the buttocks should be avoided as they can increase pressure on the perineum and worsen pain.
Nurses play a crucial role in educating clients about episiotomy care and providing appropriate pain relief measures.
Correct Answer is A
Explanation
Choice A rationale:
Lochia pooling: When a woman lies in bed, gravity causes lochia to pool in the vagina. This can result in a larger amount of
lochia being expelled when she stands up or moves around.
Reassurance: Explaining this physiological process to the client can help to reassure her that the sudden increase in lochia is
normal and not a cause for alarm.
Validation: The nurse should validate the client's feelings of concern, as it is understandable for a new mother to be anxious
about any changes in her body after childbirth.
Education: The nurse should also provide education about lochia, including its typical characteristics, duration, and expected
changes. This can help the client to anticipate and understand her postpartum experience.
Choice B rationale:
Retained placenta: While retained fragments of the placenta can cause increased lochia, this is not the most common
this possibility, especially before further assessment.
Assessment and intervention: If there is a concern for retained placenta, the nurse would conduct a thorough assessment,
including fundal height, uterine tone, and lochia characteristics. Further interventions, such as ultrasound or manual
exploration of the uterus, may be necessary.
Choice C rationale:
Urinary tract infections (UTIs): UTIs can sometimes cause an increase in lochia, but they are not typically associated with a
sudden, large gush of lochia upon standing. Other symptoms of a UTI, such as burning with urination, urgency, or frequency,
would likely be present as well.
Assessment and intervention: If a UTI is suspected, the nurse would assess for urinary symptoms and collect a urine sample
for analysis. Antibiotic treatment would be initiated if a UTI is confirmed.
Choice D rationale:
Lochia progression: The amount of lochia generally decreases over time during the postpartum period. It is heaviest in the first
few days after delivery and gradually tapers off over the course of several weeks.
Inconsistency with presentation: While this statement is true, it does not directly address the client's concern about a sudden
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