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 D
Explanation
Choice A rationale
Mongolian spots are common, benign skin markings that some newborns have, but they are not related to rubella exposure during pregnancy.
Choice B rationale
Jaundice is a common condition in newborns, characterized by a yellowing of the skin and eyes, usually due to an immature liver. It's not specifically linked to maternal rubella exposure.
Choice C rationale
Transient strabismus, or temporary misalignment of the eyes, can occur in newborns but is unrelated to rubella. It usually resolves on its own as the newborn's muscles develop.
Choice D rationale
Deafness is a significant risk associated with congenital rubella syndrome. Rubella can damage the developing auditory system in utero, leading to permanent hearing loss in the newborn.
Correct Answer is C
Explanation
Choice A rationale
History of methicillin-resistant Staphylococcus aureus (MRSA) is not directly related to the use of a cervical cap. The main concern with a cervical cap is infection, but MRSA history alone doesn't make it a contraindication for this form of contraception.
Choice B rationale
History of thrombophlebitis is more of a concern with hormonal contraceptives due to the risk of blood clots. A cervical cap does not involve hormones, so this condition is not a direct contraindication.
Choice C rationale
History of toxic shock syndrome (TSS) is a contraindication for the use of a cervical cap because the cap can increase the risk of developing TSS again. TSS is associated with prolonged use of barrier contraceptives, which can create an environment that fosters the growth of bacteria responsible for TSS.
Choice D rationale
Type 1 diabetes mellitus is not a direct contraindication for the use of a cervical cap. The concern with diabetes is often related to blood glucose control and potential infections, but it doesn't specifically contraindicate the use of cervical caps.