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?
Brisk patellar deep tendon reflexes.
Moderate amount of lochia on the perineal pad over 2 hours.
Fundus at level of umbilicus.
Approximated edges of episiotomy.
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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Correct Answer is A
Explanation
Choice A rationale
Blood pressure should be addressed first due to the client’s elevated BP (144/92 mmHg), which is a potential sign of complications such as preeclampsia.
Choice B rationale
Pulse of 99 bpm is slightly elevated but not immediately concerning compared to the high BP.
Choice C rationale
Respirations are within normal range (17/min) and do not require immediate intervention.
Choice D rationale
Temperature of 100.4°F (38.0°C) is slightly elevated but not as critical as the high BP.
Correct Answer is ["A","B","C","F"]
Explanation
Choice A rationale:
A postpartum temperature of 100.4°F (38.0°C) or higher may indicate an infection. Infections can occur after delivery, particularly if there was a manual extraction of the placenta, as in
this case. Close monitoring and further assessment are necessary to ensure the client does not develop sepsis or other complications.
Choice B rationale:
Fundal tone should be firm and well-contracted to prevent excessive bleeding postpartum. A boggy, midline fundus suggests that the uterus is not contracting effectively, increasing the
risk for postpartum hemorrhage. This requires immediate attention and intervention to ensure adequate uterine tone and control bleeding.
Choice C rationale:
Lochia should be monitored for quantity, color, and the presence of clots. Heavy lochia with small clots indicates that the client may be experiencing postpartum hemorrhage, which is a
significant concern. This can be related to uterine atony, retained placental fragments, or coagulopathies and warrants prompt evaluation and intervention.
Choice D rationale:
A respiratory rate of 17/min is within the normal adult range (12-20/min) and does not require follow-up. There are no signs of respiratory distress or abnormalities in this case, indicating
that the client's respiratory status is stable and does not necessitate further evaluation.
Choice E rationale:
A white blood cell count of 12,000/mm³ is within the expected range for postpartum women, where normal values can be elevated due to physiological stress and inflammation from
delivery. This level does not indicate infection or pathology and does not require follow-up in the context provided.
Choice F rationale:
Blood pressure of 144/92 mmHg is elevated and concerning, particularly in a postpartum client with a history of chronic hypertension and gestational diabetes. This could signal
postpartum preeclampsia or other hypertensive disorders, requiring careful monitoring and management to prevent complications like seizures, stroke, or organ damage.