What physical assessment data should the nurse consider a normal finding for a primigravida client who is 12 hours postpartum?

Unilateral lower leg pain.

Soft, spongy fundus.

Pulse rate of 56 beats/minute.

Saturating two perineal pads per hour.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Unilateral lower leg pain is not a normal finding postpartum and could indicate a deep vein thrombosis, which requires immediate medical attention.

Choice B rationale

A soft, spongy fundus is not a normal finding postpartum. The uterus should be firm to prevent excessive bleeding.

Choice C rationale

A pulse rate of 56 beats/minute can be a normal finding postpartum. Pregnancy increases blood volume and cardiac output, and these changes can persist for some time after delivery.

Choice D rationale

Saturating two perineal pads per hour is not a normal finding postpartum and could indicate excessive bleeding.

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Correct Answer is D

Explanation

Choice A rationale

While it’s true that AFP results can sometimes be false readings, it’s not the most appropriate advice for the nurse to give in this situation. Simply reassuring the client without suggesting further investigation could potentially overlook a serious condition.

Choice B rationale

Discussing options for intrauterine surgical correction of congenital defects at this stage is premature. The elevated AFP level alone does not confirm the presence of congenital defects, and suggesting surgical intervention may cause unnecessary anxiety.

Choice C rationale

Informing the client that a repeat AFP test should be conducted is a reasonable suggestion. However, it’s not the most appropriate next step in this case. A repeat test would provide more information, but it wouldn’t give definitive results about the cause of the elevated AFP level.

Choice D rationale

Explaining that a sonogram should be scheduled for definitive results is the most appropriate advice. An ultrasound can provide a more detailed view of the fetus and help identify any potential issues that might have led to the elevated AFP level. This would be the most informative next step and would guide further actions based on the findings.

A. Cervical dilation is 1 cm. B. Contractions decrease with walking. C. There is 2+ pitting edema in the lower extremities. D. The membranes are intact.

Correct Answer is B

Explanation

Choice A rationale

Cervical dilation is a sign of labor, but a dilation of 1 cm alone does not confirm active labor. It could be the early phase of labor or false labor.

Choice B rationale

Contractions that decrease with walking are typically associated with false labor. In true labor, contractions usually get stronger regardless of activity level.

Choice C rationale

While 2+ pitting edema in the lower extremities can be seen in pregnancy, it is not a reliable indicator of labor. It could be due to fluid retention or other conditions.

Choice D rationale

The status of the membranes (intact or ruptured) does not necessarily indicate whether a woman is in labor. Some women may experience membrane rupture before labor begins.

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What physical assessment data should the nurse consider a normal finding for a primigravida client who is 12 hours postpartum?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

Correct Answer is B

Explanation

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