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 D
Explanation
Choice A rationale
Phototherapy is a treatment for jaundice but is not a preventive measure. It is used after jaundice has been identified to reduce bilirubin levels in the newborn.
Choice B rationale
Suctioning excess mucus with a bulb syringe helps clear the newborn’s airways but does not have a direct role in preventing jaundice. Jaundice is related to bilirubin metabolism, not
mucus accumulation.
Choice C rationale
Preparing for an exchange blood transfusion is an intervention for severe hyperbilirubinemia but is not a preventive measure for jaundice. It is used when bilirubin levels are
extremely high.
Choice D rationale
Initiating early feeding helps to promote bowel movements, which assists in the excretion of bilirubin from the body. This is an effective preventive measure for jaundice, as it helps
reduce the chances of bilirubin buildup.
Correct Answer is C
Explanation
Choice A rationale
The placenta does not provide thermoregulation; that function is managed by maternal thermoregulation and the amniotic fluid which insulates the fetus.
Choice B rationale
Amniotic fluid cushions the fetus from maternal movements, not the placenta. The placenta's role is more focused on nutrient and waste exchange.
Choice C rationale
The placenta facilitates metabolic functions and gas exchange, supplying oxygen and nutrients to the fetus while removing carbon dioxide and waste products, ensuring fetal development.
Choice D rationale
The placenta doesn't provide a sterile environment. This is accomplished by the amniotic sac and amniotic fluid. The placenta connects the fetus to maternal blood supply, ensuring necessary exchanges for fetal growth.