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 B

Explanation

Choice B rationale

When preparing to administer magnesium sulfate to a laboring client with elevated blood pressure, ensuring that calcium gluconate is immediately available is of the highest priority. Calcium gluconate is the antidote for magnesium sulfate toxicity, and having it readily available is crucial in case of an overdose.

Choice A rationale

While assessing deep tendon reflexes (DTRs) every 4 hours is an important part of monitoring a client receiving magnesium sulfate, it is not the most immediate priority when preparing to administer the medication.

Choice C rationale

Inserting a Foley catheter with a urimeter to monitor hourly output is an important part of the overall management of a client receiving magnesium sulfate. However, it is not the most immediate priority when preparing to administer the medication.

Choice D rationale

Providing a quiet environment with subdued lighting can contribute to the comfort of a laboring client. However, it is not the most immediate priority when preparing to administer magnesium sulfate.

A. Counsel her to increase her caloric intake. B. Advise the client to breastfeed more frequently. C. Inform her that a decreased need for insulin occurs while breastfeeding. D. Schedule an appointment for the client with the diabetic nurse educator.

Correct Answer is C

Explanation

Choice A rationale

While increasing caloric intake can be beneficial for breastfeeding mothers, it does not directly address the client’s concern about decreased insulin needs.

Choice B rationale

Advising the client to breastfeed more frequently does not directly address the client’s concern about decreased insulin needs.

Choice C rationale

Breastfeeding can lead to a decreased need for insulin in some individuals. This is because lactation requires energy, and this energy demand can affect the mother’s insulin requirements.

Choice D rationale

While scheduling an appointment with the diabetic nurse educator can be helpful, it is not the immediate response to the client’s concern about decreased insulin needs.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing to administer magnesium sulfate to a laboring client whose blood pressure has risen from 110/60 mmHg to 140/90 mmHg.Which nursing protocol is of the highest priority?

Correct Answer is B

Explanation

A new mother, who is breastfeeding her 4-week-old infant and has type I diabetes, reports that her insulin needs have decreased since the birth of her child.What action should the nurse take?

Correct Answer is C

Explanation

After breastfeeding for 10 minutes on each breast, a new mother calls the nurse to the postpartum room to assist with changing the newborn’s diaper. As the mother begins the diaper change, the newborn regurgitates the breast milk. What should be the nurse’s first action?

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A mother inquires about what to use when changing her newborn’s diaper. What should the nurse recommend to this mother?

The healthcare provider prescribes magnesium sulfate 4 grams intravenously (IV) to be infused over 20 minutes for a client with preeclampsia. The IV bag contains magnesium sulfate 20 grams in dextrose 5% in water 500 mL. How many mL/hour should the nurse program the infusion pump?