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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

Uteroplacental insufficiency leads to late decelerations, which are characterized by a gradual decrease in fetal heart rate after the peak of a contraction. This indicates compromised blood flow between the uterus and placenta, affecting the fetus.

Choice B rationale

Umbilical cord compression usually causes variable decelerations, not late decelerations.

Choice C rationale

Maternal bradycardia does not cause changes in fetal heart rate patterns like late decelerations.

Choice D rationale

Fetal head compression causes early decelerations, which coincide with contractions, not late decelerations.

Correct Answer is C

Explanation

Choice A rationale

Category 1 is a normal fetal heart rate pattern with no signs of fetal distress, which is not applicable in this case.

Choice B rationale

Category 2 represents an intermediate category with some concerns, but recurrent late decelerations and absent variability place this scenario in a higher risk category.

Choice C rationale

Category 3 indicates abnormal fetal heart rate patterns, including absent variability with recurrent late decelerations, which is associated with potential fetal hypoxia or acidemia and requires prompt intervention.

Choice D rationale

There is no Category 4 in fetal heart rate monitoring.

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