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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A rationale

While nausea and vomiting can occur in the postpartum period, they are not the highest priority for a client with a history of rheumatic fever and heart damage. These symptoms are usually self-limiting and can be managed with antiemetics.

Choice B rationale

Fluid volume excess is the highest priority for a client with a history of rheumatic fever and heart damage. Rheumatic heart disease can result in impaired heart function, making it difficult for the heart to handle increased fluid volumes that occur during pregnancy and the postpartum period. This can lead to heart failure.

Choice C rationale

While sleep deprivation can occur in the postpartum period, it is not the highest priority for a client with a history of rheumatic fever and heart damage. Adequate rest is important for recovery, but it does not directly address the client’s risk of heart failure.

Choice D rationale

While infection is a concern in the postpartum period, it is not the highest priority for a client with a history of rheumatic fever and heart damage. While infection can exacerbate heart failure, the immediate concern is managing the client’s fluid volume to prevent heart failure.

A. Notify the healthcare provider of the assessment findings. B. Obtain a STAT hemoglobin and hematocrit. C. Determine if the client received anesthesia during delivery. D. Assign a practical nurse (PN) to reassess the client’s vital signs.

Correct Answer is C

Explanation

Choice A rationale

While notifying the healthcare provider of the assessment findings is important, it would not be the first action to take. The nurse should first gather more information about the client’s condition.

Choice B rationale

Obtaining a STAT hemoglobin and hematocrit would not be the first action to take. These tests could provide information about the client’s blood volume and potential for anemia, but they would not directly address the client’s complaint of a severe headache.

Choice C rationale

Determining if the client received anesthesia during delivery is the correct first action. A severe headache in the postpartum period can be a sign of a post-dural puncture headache, which can occur as a complication of spinal or epidural anesthesia.

Choice D rationale

Assigning a practical nurse (PN) to reassess the client’s vital signs would not be the first action to take. While ongoing monitoring of the client’s vital signs is important, the nurse should first investigate the potential cause of the client’s severe headache.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

Correct Answer is B

Explanation

Correct Answer is C

Explanation

Which type of anesthesia, when used with a laboring client, results in a loss of sensation confined to the vagina and perineum?

A 25-year-old client experienced a severe postpartum hemorrhage following the vaginal birth of twins and is now transferred to the postpartum unit.What complication should the nurse prioritize during the client’s assessment?

What should be the primary focus of nursing care in the transitional phase of labor for a client who anticipates an unmedicated delivery?

During the newborn admission assessment, the nurse palpates the newborn’s scrotum and does not feel the testicles. Which assessment technique should the nurse perform next to verify the absence of testes?

One day after vaginal delivery of a full-term baby, a postpartum client’s white blood cell count is 15,000/mm (15 x 109/L). What action should the nurse take first?

A client who is 3 weeks postpartum tells the nurse, “I am so tired all the time. I didn’t realize having a baby would be this challenging.”. What should the nurse’s response be?

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?

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