A nurse is assisting with the care of a postpartum female client who delivered vaginally 8 hours ago in the maternity unit.
Exhibit 1: Vital Signs
0700:
- Temperature: 36.2°C (97.2°F)
- Heart rate: 80/min
- Respiratory rate: 16/min
- Blood pressure: 136/82 mm Hg
1100:
- Temperature: 37.2°C (99.0°F)
- Heart rate: 85/min
- Respiratory rate: 18/min
- Blood pressure: 136/86 mm Hg
- Pulse oximetry: 99%
Exhibit 2: Nurses' Notes
0700: The client's breasts were soft, and nipples were intact. The uterus was palpated as firm, midline, and at the level of the umbilicus. There was a moderate amount of lochia rubra. The episiotomy site was well approximated with mild edema and ecchymosis. The client reported pain as 2 on a scale of 0 to 10. She was able to void spontaneously, with no bladder distention. Deep tendon reflexes were 1+. Peripheral edema was 2+ in bilateral lower extremities.
1100: The client's breasts remained soft, and nipples were intact. The uterus was palpated as soft with lateral deviation and 1 cm above the umbilicus. There was a large amount of lochia rubra. The episiotomy site was well approximated with mild edema and ecchymosis. The client reported pain as 3 on a scale of 0 to 10. Deep tendon reflexes were 1+. Peripheral edema was 2+ in bilateral lower extremities.
Querry
Select the 3 findings that require immediate follow-up.
Deep tendon reflexes 1+
Lateral deviation of the uterus
Blood pressure 136/86 mm Hg
Pain rating of 3 on a scale of 0 to 10
Breasts soft
Uterine tone soft
Large amount of lochia rubra
Peripheral edema 2+ in bilateral lower extremities
Correct Answer : B,F,G
Choice A rationale:
Deep tendon reflexes of 1+ are considered normal for a postpartum client and do not typically require immediate follow-up. They indicate slight but definite muscle contraction with reinforcement.
Choice B rationale:
Lateral deviation of the uterus can indicate bladder distension, which can interfere with uterine contraction and increase the risk of postpartum hemorrhage. Immediate follow-up is necessary to address this issue.
Choice C rationale:
A blood pressure of 136/86 mm Hg is within the normal range for a postpartum client and does not require immediate follow-up unless there are other symptoms of preeclampsia or hypertension.
Choice D rationale:
A pain rating of 3 on a scale of 0 to 10 is mild and is expected in the postpartum period. It does not require immediate follow-up unless the pain is severe or unrelieved.
Choice E rationale:
Soft breasts in the immediate postpartum period are normal as milk production has not yet fully begun. This does not require immediate follow-up.
Choice F rationale:
A soft uterine tone indicates uterine atony, which can lead to postpartum hemorrhage. This requires immediate follow-up and intervention to ensure the uterus is contracting properly.
Choice G rationale:
A large amount of lochia rubra can be a sign of postpartum hemorrhage. Immediate follow-up is necessary to assess and manage bleeding.
Choice H rationale:
Peripheral edema of 2+ in the bilateral lower extremities is common in postpartum clients due to fluid shifts and does not typically require immediate follow-up unless accompanied by other concerning symptoms.
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Correct Answer is B
Explanation
Choice A rationale
Using a disposable razor for shaving while taking warfarin can increase the risk of cuts and bleeding, which should be avoided due to the anticoagulant effects of warfarin.
Choice B rationale
Oral contraceptives should not be taken while on warfarin because they can increase the risk of blood clots, counteracting the effect of the anticoagulant.
Choice C rationale
Stopping warfarin in 2 weeks is incorrect advice, as the duration of therapy varies depending on the condition being treated and the individual's response to the medication.
Choice D rationale
Taking 650 milligrams of aspirin for leg discomfort is not advised while on warfarin, as aspirin can increase the risk of bleeding by affecting platelet function and the blood clotting process.
Correct Answer is D
Explanation
Choice A rationale
Instructing the client to apply anesthetic spray to the site three to four times a day is incorrect. While anesthetic sprays can help with pain relief, it's more important to manage swelling and discomfort with a combination of methods, including ice packs and perineal care.
Choice B rationale
Encouraging the client to change perineal pads at least three times a day is insufficient. Pads should be changed more frequently to maintain hygiene and prevent infection.
Choice C rationale
Assisting the client to fill the squeeze bottle with cold water to perform perineal care is incorrect. While perineal care is important, cold water is not typically recommended as it may not provide comfort and might even cause discomfort.
Choice D rationale
Alternating warm and ice packs to the site every 2 hours for the first 24 hours postpartum is correct. This method helps manage pain and swelling effectively, promoting healing and comfort for the client.