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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 D

Explanation

Choice A rationale

Severe nausea and vomiting, known as hyperemesis gravidarum, are more commonly associated with high levels of human chorionic gonadotropin (hCG) and are not specific to

ectopic pregnancy.

Choice B rationale

While vaginal bleeding can occur in an ectopic pregnancy, it is usually not a large amount. The bleeding in ectopic pregnancy tends to be light and irregular.

Choice C rationale

Uterine enlargement greater than expected for gestational age is typically associated with conditions like molar pregnancy, not ectopic pregnancy, as the pregnancy is located outside

the uterus.

Choice D rationale

Unilateral, cramp-like abdominal pain is a classic symptom of ectopic pregnancy as the fertilized egg implants outside the uterus, most commonly in a fallopian tube, causing

localized pain.

Correct Answer is A

Explanation

Choice A rationale

Anaphylactoid syndrome of pregnancy (also known as amniotic fluid embolism) occurs when amniotic fluid, fetal cells, hair, or other debris enter the mother's bloodstream, triggering

a serious reaction. It can cause sudden shortness of breath, cardiovascular collapse, and other severe symptoms immediately after a rupture of membranes and is a rare but critical

obstetrical emergency.

Choice B rationale

Abruptio placentae involves the premature separation of the placenta from the uterine wall, which leads to bleeding and potential fetal and maternal distress. However, it does not

typically present with sudden cardiorespiratory collapse or shortness of breath immediately following membrane rupture.

Choice C rationale

Uterine rupture refers to a tear in the wall of the uterus, usually due to trauma, labor stress, or previous surgical scars. While it is a severe condition, it usually presents with

abdominal pain, vaginal bleeding, and fetal distress rather than sudden respiratory failure.

Choice D rationale

Disseminated intravascular coagulation (DIC) is a condition affecting blood clotting processes, often secondary to other conditions like severe preeclampsia, sepsis, or trauma. It

generally presents with bleeding and clotting issues but not sudden respiratory or cardiovascular collapse.

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