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

Question Solution

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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A. Insert the suppository 5 cm. B. Apply petroleum jelly to the suppository. C. Assist the client into a prone position. D. Insert the suppository along the posterior vaginal wall.

Correct Answer is D

Explanation

Choice A rationale

Inserting the suppository 5 cm is generally insufficient for proper placement. The suppository needs to be placed further along the vaginal canal to be effective.

Choice B rationale

Applying petroleum jelly to the suppository is not recommended because it can interfere with the absorption and effectiveness of the medication.

Choice C rationale

Assisting the client into a prone position is not appropriate for inserting a vaginal suppository. The client should be in a lithotomy or supine position with legs bent.

Choice D rationale

Inserting the suppository along the posterior vaginal wall ensures proper placement and maximizes the effectiveness of the medication by allowing it to dissolve and be absorbed where it is needed.

A. "You will be tested again for GBS at about 36 weeks of gestation.”. B. "If you test positive for GBS, the provider will need to perform a cesarean birth.”. C. "You will take an antibiotic during the last 2 weeks of pregnancy to avoid transferring GBS to your baby.”. D. "This infection can cause your baby to experience hearing loss at birth.”.

Correct Answer is A

Explanation

Choice A rationale

Testing for GBS at around 36 weeks of gestation is standard practice to identify carriers and prevent neonatal GBS infections through intrapartum antibiotic prophylaxis if necessary.

Choice B rationale

Cesarean birth is not indicated solely based on a positive GBS status. The primary intervention is intrapartum antibiotic prophylaxis to reduce the risk of neonatal infection.

Choice C rationale

Routine antibiotic administration during the last weeks of pregnancy is not standard practice; antibiotics are given during labor if GBS is present to prevent transmission to the baby.

Choice D rationale

GBS infection does not cause hearing loss in newborns. The primary concern is neonatal sepsis, pneumonia, or meningitis, not hearing loss.

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Correct Answer is D

Explanation

Correct Answer is A

Explanation

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A nurse is administering a miconazole vaginal suppository to a client who has vaginal candidiasis. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is reinforcing teaching with a client who tested positive for group B streptococcus β-hemolytic (GBS) during a prior pregnancy and is at 30 weeks of gestation. Which of the following statements should the nurse make?

Correct Answer is A

Explanation

A nurse is caring for a client who inquires about a cervical cap for contraception. The nurse should identify that which of the following manifestations is a contraindication for the use of a cervical cap?

A nurse is caring for a client who is at 41 weeks of gestation. The nurse should understand that which of the following findings can indicate a prenatal complication in this client?

A nurse is caring for a client who is at 12 weeks of gestation and has hyperemesis gravidarum. Which of the following manifestations should the nurse expect?

A nurse is contributing to the plan of care for a client who is in early labor and reports low-back pain during contractions. Which of the following interventions should the nurse include in the plan?

A nurse is caring for a client who is at 39 weeks of gestation and is in active labor. The nurse notes maternal exposure to rubella during pregnancy. After delivery, the nurse should monitor the newborn for which of the following conditions?

A nurse is reinforcing discharge teaching with a client who is pregnant and was treated for a urinary tract infection. Which of the following should the nurse include in the discharge instructions? (Select all that apply.)

A nurse is assisting in the care of a client who is in labor and requires intermittent fetal monitoring. Which of the following actions should the nurse take?

A nurse is caring for a client who is postpartum and has an episiotomy. Which of the following actions should the nurse take?

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