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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View Related questions
Correct Answer is B
Explanation
Choice A rationale
Hyperbilirubinemia presents with jaundice (yellowing of the skin and eyes) and is caused by excess bilirubin in the blood. It doesn't typically involve a high-pitched cry, increased
muscle tone, or projectile vomiting.
Choice B rationale
Neonatal abstinence syndrome occurs in newborns exposed to addictive opiate drugs while in the mother’s womb. Symptoms include high-pitched crying, increased muscle tone,
yawning, poor feeding with vomiting, and tachypnea due to drug withdrawal.
Choice C rationale
Respiratory distress syndrome is primarily characterized by breathing difficulties, including rapid, shallow breathing and a grunting sound. Symptoms do not typically include high-
pitched cry or projectile vomiting.
Choice D rationale
Necrotizing enterocolitis involves severe inflammation and necrosis of the intestines. Symptoms include abdominal distension, vomiting bile, bloody stools, and apnea but not a high-
pitched cry or increased muscle tone.
Correct Answer is C
Explanation
Choice A rationale
A reaction from an epidural can cause side effects such as hypotension and shivering, but it is not related to tachysystole.
Choice B rationale
When the fetus's heart rate drops below baseline, it is termed bradycardia, not tachysystole. This condition can occur due to various reasons, including cord prolapse or placental insufficiency.
Choice C rationale
Tachysystole is defined as more than five contractions in 10 minutes. This condition can lead to reduced blood flow to the fetus, resulting in fetal distress.
Choice D rationale
Pitocin is a medication used to induce labor and can cause tachysystole, but the administration of Pitocin itself is not the definition of tachysystole. It's the increased frequency of contractions that defines the condition.