The nurse reviews the client's history and physical to determine the cause of the client's symptoms.
Highlight the information from the history and physical that requires further evaluation.

A primiparous client was induced at 41-weeks gestation with misoprostol and oxytocin.

She gave birth vaginally 4 days ago, and her prenatal course and delivery were uncomplicated.

Client called her healthcare provider (HCP) this morning with fatigue, new-onset of headache and pain in the right upper quadrant of the abdomen not relieved with ibuprofen.

The client records a home blood pressure reading of 154/100 mm Hg.

Answer and Explanation

Correct Answer : C,D

Choice A rationale

A primiparous client induced at 41 weeks with misoprostol and oxytocin is a common and appropriate labor management strategy. Misoprostol is a prostaglandin analog used for cervical ripening, and oxytocin is a synthetic hormone that stimulates uterine contractions. These interventions are standard practice and do not inherently indicate a pathological condition requiring further evaluation in the postpartum period.

Choice B rationale

A vaginal delivery 4 days ago after an uncomplicated prenatal course is a normal and expected event. The timing of the delivery and the lack of complications during pregnancy or childbirth do not suggest a current pathological state. This information provides a baseline of a healthy pregnancy and delivery, which helps in identifying any deviations that may have occurred postpartum.

Choice C rationale

New-onset headache and pain in the right upper quadrant of the abdomen, especially when not relieved by an analgesic like ibuprofen, are concerning symptoms in the postpartum period. The right upper quadrant pain may indicate liver capsule distension, a sign of liver involvement. This cluster of symptoms can be indicative of a severe postpartum complication, such as preeclampsia.

Choice D rationale

A home blood pressure reading of 154/100 mm Hg is a significant finding. Normal blood pressure is typically below 120/80 mm Hg. This reading meets the criteria for hypertension, a key feature of preeclampsia. Hypertension in the postpartum period, especially when accompanied by other symptoms, is a serious medical concern and necessitates immediate further evaluation and management.

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Correct Answer is A

Explanation

Choice A rationale

Expulsion of the products of conception is a form of spontaneous abortion. The most immediate risk to the client is postpartum hemorrhage. The nurse must assess for uterine bleeding and firmness of the fundus, which indicates the uterus is contracting and clamping down blood vessels. A soft or boggy uterus is a sign of uterine atony and increases the risk of hemorrhage.

Choice B rationale

Providing emotional support is a crucial nursing intervention, but it is not the most important in the immediate aftermath of a spontaneous abortion. The client's physical stability and safety are the highest priority. Once the nurse has addressed the immediate physiological needs and ensured the client is stable, then emotional support can be provided.

Choice C rationale

Notifying the healthcare provider is an important step, but it follows the initial assessment of the client's physical status. The nurse must first gather essential information regarding the client's bleeding and fundal tone to provide a complete report. This ensures that the provider can make informed decisions about further interventions.

Choice D rationale

Removing the expelled material is part of providing hygienic care and comfort to the client. While important, it is not the most critical intervention. The immediate life-threatening risk is postpartum hemorrhage, which is addressed by assessing uterine bleeding and fundal firmness. Physical stability takes precedence over environmental cleanup.

A. Assess the infant's response to auditory stimuli. B. Notify the healthcare provider of the findings. C. Document the findings in the electronic medical record. D. Tell the mother that the infant needs a further assessment.

Correct Answer is B

Explanation

Choice A rationale

Assessing the infant's response to auditory stimuli is a component of a comprehensive neurological examination. However, the absence of a primitive reflex, such as the Moro reflex, which should be present at this age, is a significant abnormal finding indicative of a potential neurological deficit. Therefore, this action is a secondary step after addressing the primary concern.

Choice B rationale

The absence of the Moro reflex in a 1-month-old infant is a critical finding that suggests a potential neurological impairment, possibly affecting the central nervous system or musculoskeletal system. Normal Moro reflex should be present from birth until around 3 to 4 months of age. Prompt notification of the healthcare provider is necessary to ensure a timely and thorough evaluation of the infant's neurological status.

Choice C rationale

Documentation is a crucial part of nursing practice, but it is not the first intervention. The nurse must first act on the abnormal finding to ensure the safety and well-being of the infant. The priority is to communicate the significant assessment finding to the healthcare provider so a plan of care can be established.

Choice D rationale

While patient education is important, simply telling the mother that a further assessment is needed does not constitute a primary intervention. The nurse's immediate responsibility is to address the clinical finding with the medical team. The healthcare provider will then order the necessary diagnostic tests and treatments, and the nurse can provide education.

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The nurse reviews the client's history and physical to determine the cause of the client's symptoms. Highlight the information from the history and physical that requires further evaluation.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client at 17-weeks gestation expels the products of conception in her bed. Which intervention is most important for the nurse to implement?

Correct Answer is A

Explanation

The nurse is assessing the neurological system of a 1-month-old infant. During the exam, the infant demonstrates an absence of the startle (Moro) reflex. Which intervention should the nurse implement first?

Correct Answer is B

Explanation

A 32-week multigravida client with a history of preeclampsia arrives to the clinic for her routine appointment. The nurse observes the client has an elevated blood pressure of 155/90 mm Hg. Which action should the nurse take?

The school nurse is presenting a seminar to parents about child safety that focuses on the prevention of spinal cord injuries. Which information is most important for the nurse to include in the teaching plan?

What is the most likely cause of the client's symptoms, and what is the nurse's priority intervention?

At 0600 while admitting a woman for a scheduled repeat cesarean section (C-section), the client tells the nurse that she drank a cup of coffee at 0400 because she wanted to avoid getting a headache. Which action should the nurse take first?

The nurse reviews the client's history and physical to determine the cause of the client's symptoms. Highlight the information from the history and physical that requires further evaluation.

A client with severe preeclampsia is receiving magnesium sulfate. The nurse notes the following vital signs: blood pressure 146/90 mm Hg at 1220 and 141/86 mm Hg at 1230. What is the most appropriate action for the nurse to take?

A woman is in the second stage of labor where the fetal head has just been born and the nurse observes the immediate retraction of the head against the perineum. Which action should the nurse expect to perform to assist the healthcare provider (HCP)?

A client at 38-weeks gestation reports severe abdominal pain. Upon palpation, the nurse notes that the abdomen is rigid. How should the nurse document the findings?

The nurse reviews the client's history and physical to determine the cause of the client's symptoms.
Highlight the information from the history and physical that requires further evaluation.