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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 C

Explanation

Choice A rationale

Irregular menses are not a direct risk factor for cervical cancer. While they can indicate hormonal imbalances, they are not strongly linked to cervical cancer risk.

Choice B rationale

Menopausal status and hormone replacement therapy (HRT) are more closely linked to breast cancer risks rather than cervical cancer. Cervical cancer is primarily associated with HPV infection.

Choice C rationale

Multiple sexual partners increase the risk of HPV infection, which is the primary cause of cervical cancer. HPV is a sexually transmitted infection that significantly raises the likelihood of developing cervical cancer.

Choice D rationale

A family history of breast cancer is more relevant to breast cancer risk rather than cervical cancer. Cervical cancer risk is more closely linked to HPV infection and sexual behavior.

Correct Answer is A

Explanation

Choice A rationale

Administering antipyretics for maternal fever is essential as elevated maternal temperatures can increase the risk of fetal tachycardia and potentially lead to fetal distress. Reducing

fever promptly is a priority to stabilize both maternal and fetal conditions.

Choice B rationale

Preparing for an emergency cesarean section is not the immediate step for maternal fever; instead, managing the fever and assessing the need for further interventions based on the

overall clinical picture should be prioritized.

Choice C rationale

Administering glucocorticoids is indicated for promoting fetal lung maturity in preterm labor, not specifically for maternal fever management. Fever management requires antipyretics

and hydration.

Choice D rationale

Waiting 4 hours to recheck temperature delays prompt management, increasing risks for both the mother and fetus. Immediate action to reduce fever is crucial to prevent potential

complications.

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