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A nurse is assessing a client who is 4 hours postpartum following a vaginal delivery.
Which of the following findings should the nurse identify as the priority?

A.

Brisk patellar deep tendon reflexes.

B.

Moderate amount of lochia on the perineal pad over 2 hours.

C.

Fundus at level of umbilicus.

D.

Approximated edges of episiotomy.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Brisk patellar deep tendon reflexes can indicate central nervous system irritability, which might suggest conditions like preeclampsia or eclampsia if accompanied by other symptoms. It's critical to assess and monitor for further complications.

 

Choice B rationale

A moderate amount of lochia on the perineal pad over 2 hours is normal postpartum bleeding and does not typically indicate an immediate concern if within expected ranges.

 

Choice C rationale

A fundus at the level of the umbilicus is an expected finding 4 hours postpartum and indicates normal uterine involution. It is not a priority concern at this stage.

 

Choice D rationale

Approximated edges of an episiotomy indicate that the incision is healing properly without signs of infection or dehiscence. This is a normal and expected finding in the postpartum period.


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View Related questions

Correct Answer is B

Explanation

Choice A rationale

Open heart surgery is unrelated to the development of vaginal fistulas.

Choice B rationale

Tissue trauma from childbirth can cause vaginal fistulas, as prolonged labor or obstetric interventions can damage vaginal tissue and lead to fistula formation.

Choice C rationale

Diabetes mellitus does not directly cause vaginal fistulas, although it can affect overall tissue health and healing.

Choice D rationale

Preeclampsia, while a serious pregnancy complication, is not a direct cause of vaginal fistulas.

Correct Answer is C

Explanation

Choice A rationale

G4T1 P1 A1 L2 implies the client has been pregnant 4 times, with 1 term birth, 1 preterm birth, 1 abortion, and 2 living children. This does not include the correct number of

pregnancies or abortions for this client.

Choice B rationale

G5T2 P0 A2 L2 indicates 5 pregnancies, 2 term births, no preterm births, 2 abortions, and 2 living children. This does not correctly account for the preterm birth and abortion history

provided.

Choice C rationale

G5T1 P1 A2 L2 is the correct answer, as it denotes 5 pregnancies (including the current one), 1 term birth, 1 preterm birth, 2 abortions, and 2 living children, aligning with the client's

history.

Choice D rationale

G5T1 P1 A1 L3 indicates 5 pregnancies, 1 term birth, 1 preterm birth, 1 abortion, and 3 living children. The client has only 2 living children, so this is incorrect.

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