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Select all that apply. Which of the following findings require immediate follow-up?

Exhibits

Temperature

Pulse rate

Respiratory rate

Blood pressure

Lochia

Pain

Edema

Answer and Explanation

Correct Answer : A,B,D,E,G

Choice A rationale: The client’s temperature is 38.3°C (101°F), which is above the normal range (36.5-37.2°C or 97.7-99°F). This could indicate an infection, which is a common postpartum complication. Fever in the postpartum period can be due to endometritis, wound infection, mastitis, or urinary tract infection. Given the client’s report of a burning sensation during urination, a urinary tract infection could be a possibility. This finding requires immediate follow-up.

Choice B rationale: The client’s pulse rate is 110/min, which is above the normal range (60-100/min). This could indicate tachycardia, which can be a response to fever, pain, anxiety, or blood loss. Given the client’s elevated temperature and report of pain, this finding requires immediate follow-up.

Choice C rationale: The client’s respiratory rate is 22/min, which is within the normal range (12-20/min). While it’s slightly elevated, it’s not as concerning as the other findings. However, the nurse should continue to monitor the client’s respiratory rate along with other vital signs.

Choice D rationale: The client’s blood pressure is 140/90 mm Hg, which is higher than the normal range (90-120/60-80 mm Hg). This could indicate hypertension, which can be a complication in the postpartum period. Hypertension can lead to complications such as preeclampsia or eclampsia, which can be life-threatening. This finding requires immediate follow-up.

Choice E rationale: The client has a large amount of lochia rubra. Lochia rubra is normal for the first few days after delivery, but a large amount could indicate postpartum hemorrhage, especially if it’s accompanied by signs of hypovolemia such as tachycardia and hypotension. This finding requires immediate follow-up.

Choice F rationale: The client reports pain as 5 on a scale of 0 to 10. While pain is expected after a vaginal delivery, especially with an episiotomy, it should be manageable with analgesics. If the client’s pain is not well-controlled, it could indicate a complication such as infection or hematoma at the episiotomy site. However, given the information provided, this finding does not require immediate follow-up as much as the others.

Choice G rationale: The client has 3+ peripheral edema in bilateral lower extremities. While some edema is normal during pregnancy and the postpartum period, 3+ edema could indicate a complication such as deep vein thrombosis, especially if it’s accompanied by pain, warmth, or redness. This finding requires immediate follow-up.

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Correct Answer is C

Explanation

Choice A rationale
Performing a fundal massage is not the appropriate action for a client with placenta previa who is experiencing a large amount of vaginal bleeding. Fundal massage is typically used to stimulate contractions and reduce postpartum hemorrhage after the delivery of the placenta. However, in the case of placenta previa, where the placenta is covering the cervix, a fundal massage could potentially cause more harm and increase bleeding.
Choice B rationale
Assessing for abdominal tenderness is not the most immediate action for a nurse to take when a client with placenta previa is exhibiting a large amount of vaginal bleeding. While abdominal tenderness could indicate a complication such as placental abruption, the primary concern with placenta previa is the risk of severe bleeding that can endanger both the mother and the baby.
Choice C rationale
Obtaining serial hemoglobin and hematocrit is the correct action in this situation. These laboratory tests are important for monitoring the client’s blood loss and determining the need for a possible blood transfusion. With a large amount of vaginal bleeding, the client is at risk for anemia and hypovolemic shock, so close monitoring of blood levels is crucial.

Choice C rationale

Monitoring vital signs closely is an important part of care for any client, but it is not the most specific action a nurse should take for a client with placenta previa who is experiencing a large amount of vaginal bleeding. Vital sign changes could indicate worsening of the client’s condition, but these changes often occur late in the progression of blood loss. Therefore, while important, it is not the most immediate action to take.

A. Move the client onto their hands and knees B. Apply pressure to the client’s fundus C. Assist the client in pulling their knees toward their abdomen D. Press firmly on the client’s suprapubic area

Correct Answer is C

Explanation

Choice A rationale
Moving the client onto their hands and knees is not the primary action taken during the McRoberts maneuver. The McRoberts maneuver involves an obstetrician or other healthcare provider flexing the patient’s thighs toward their abdomen.
Choice B rationale

Applying pressure to the client’s fundus is not the primary action taken during the McRoberts maneuver. The McRoberts maneuver involves an obstetrician or other healthcare provider flexing the patient’s thighs toward their abdomen.
Choice C rationale
This is the correct answer. The McRoberts maneuver involves an obstetrician or other healthcare provider flexing the patient’s thighs toward their abdomen. This maneuver helps to rotate the pelvis and open the sacrum to release the baby’s shoulder.
Choice D rationale
Pressing firmly on the client’s suprapubic area is not the primary action taken during the McRoberts maneuver. The McRoberts maneuver involves an obstetrician or other healthcare provider flexing the patient’s thighs toward their abdomen.

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Select all that apply. Which of the following findings require immediate follow-up? Exhibits

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is at 32 weeks of gestation and has placenta previa. The client is exhibiting a large amount of vaginal bleeding.What actions should the nurse take?

Correct Answer is C

Explanation

A nurse is caring for a client who is in the second stage of labor and is experiencing a shoulder dystocia. The provider instructs the nurse to perform the McRoberts maneuver.Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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Select all that apply. Which of the following findings require immediate follow-up?

Exhibits