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A nurse is assisting with the care of a postpartum client who delivered vaginally 8 hours ago.Select the findings that require immediate follow-up.

A.

Deep tendon reflexes 1+.

B.

Blood pressure 136/86 mm Hg.

C.

Pain rating of 3 on a scale of 0 to 10.

D.

Large amount of lochia rubra.

E.

Peripheral edema 2+ bilateral lower extremities.

F.

Breasts soft.

G.

Uterine tone soft.

H.

Lateral deviation of the uterus.

Question Solution

Correct Answer : D,G,H

Choice A rationale

 

Deep tendon reflexes of 1+ are considered within normal limits and do not require immediate follow-up. This finding is not indicative of any acute complications.

 

Choice B rationale

 

A blood pressure reading of 136/86 mm Hg is slightly elevated but not critically high. It does not indicate an immediate risk and can be monitored with routine care.

 

Choice C rationale

 

A pain rating of 3 on a scale of 0 to 10 is mild and manageable. It does not necessitate immediate follow-up unless there is a sudden and significant increase in pain.

 

Choice D rationale

 

A large amount of lochia rubra can be a sign of excessive bleeding and requires immediate follow-up to assess for postpartum hemorrhage. This finding is concerning and needs prompt attention.

 

Choice E rationale

 

Peripheral edema of 2+ in bilateral lower extremities is common in the postpartum period due to fluid shifts and should resolve naturally. It does not require immediate follow-up unless it worsens or is accompanied by other symptoms.

 

Choice F rationale

 

Soft breasts are normal postpartum when milk has not yet come in or if the client is not breastfeeding. This finding does not require immediate follow-up as it is a normal occurrence.

 

Choice G rationale

 

A soft uterine tone can indicate uterine atony, which can lead to hemorrhage. Immediate follow-up is necessary to prevent potential complications such as postpartum hemorrhage.

 

Choice H rationale

 

Lateral deviation of the uterus can indicate a displaced uterus, possibly due to a full bladder or other reasons, which requires prompt attention. This finding could lead to complications if not addressed promptly.


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View Related questions

Correct Answer is B

Explanation

Choice A rationale

There is no need to fast before a nonstress test. The test measures the fetal heart rate in response to fetal movements and does not require any dietary restrictions.

Choice B rationale

During a nonstress test, the client will press a button whenever they feel the baby move. This helps correlate fetal movements with heart rate changes.

Choice C rationale

The client is not required to lie flat on their back for the duration of the test. They can be in a semi-reclined position to ensure comfort and avoid supine hypotensive syndrome.

Choice D rationale

Medication to stimulate contractions is not used during a nonstress test. This is done during a contraction stress test, which is a different procedure.

Correct Answer is D

Explanation

Choice A rationale

Tetracycline is contraindicated in pregnancy due to its potential to cause fetal harm, including teeth discoloration and inhibition of bone growth.

Choice B rationale

Acyclovir is an antiviral medication used to treat herpes infections, not chlamydia.

Choice C rationale

Metronidazole is used to treat bacterial vaginosis and trichomoniasis, not chlamydia.

Choice D rationale

Amoxicillin is a safe and effective antibiotic for treating chlamydia in pregnant women. It is preferred due to its safety profile and effectiveness.

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