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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 A

Explanation

Choice A rationale

A newborn who is 26 hours post-delivery and has had no urine output needs immediate attention. Lack of urine output for over 24 hours may indicate dehydration or renal issues. Immediate medical evaluation is required to identify underlying conditions and prevent complications such as acute kidney injury or sepsis.

Choice B rationale

Acrocyanosis, characterized by blueish discoloration of the extremities, is common in newborns during the first 24-48 hours of life and usually resolves on its own. It occurs due to immature blood circulation and is generally not a cause for concern.

Choice C rationale

Failure to pass meconium within the first 24 hours can be a sign of conditions like Hirschsprung's disease or cystic fibrosis, but it is not as immediately concerning as anuria (no urine output). Monitoring and further evaluation are necessary, but it does not require urgent provider notification.

Choice D rationale

A blood glucose level of 50 mg/dL in a newborn is within the lower limit of normal. While it's important to monitor, it does not necessitate immediate provider notification unless it continues to drop or other symptoms arise.

Correct Answer is ["A","C","D","E"]

Explanation

Choice A rationale

Recurrent variable decelerations can indicate umbilical cord compression. Notifying the provider ensures immediate intervention if necessary to address potential fetal distress and to

monitor labor progression.

Choice B rationale

Ambulation is not recommended with recurrent variable decelerations. It might increase the risk of cord prolapse or other complications, further compromising fetal wellbeing.

Choice C rationale

Repositioning to the left lateral position helps improve uteroplacental blood flow and reduce cord compression, addressing the decelerations and promoting fetal oxygenation.

Choice D rationale

Performing a sterile vaginal exam can help identify any immediate issues like cord prolapse or rapid cervical changes that could impact labor management and fetal wellbeing.

Choice E rationale

Providing an IV fluid bolus can improve maternal hydration and placental perfusion, potentially alleviating the cause of variable decelerations by increasing blood flow and reducing cord

compression effects. .

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