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
Uterine atony is a common complication following polyhydramnios because the excessive amniotic fluid can lead to uterine overdistension, which in turn can cause poor uterine
muscle tone and increased risk of postpartum hemorrhage.
Choice B rationale
Thrombophlebitis is an inflammation of a vein with clot formation, but it is not directly associated with polyhydramnios.
Choice C rationale
Postpartum preeclampsia is high blood pressure and signs of organ damage after delivery, but there is no direct link between polyhydramnios and this condition.
Choice D rationale
Retained placental fragments can lead to postpartum hemorrhage but are not specifically associated with polyhydramnios.
Correct Answer is B
Explanation
Choice A rationale
Copious vernix is typically found on preterm newborns, not those born post-term.
Choice B rationale
Dry, cracked skin is a common finding in post-term newborns due to prolonged exposure to amniotic fluid.
Choice C rationale
Decreased subcutaneous fat is more likely in preterm newborns, while post-term newborns might lose some fat due to nutrient depletion.
Choice D rationale
Scant scalp hair is more common in preterm infants, whereas post-term infants usually have more developed hair. .