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.

Free Nursing Test Bank

Take full exam free

View Related questions

A. Assist the client's partner to apply counterpressure to the sacrum. B. Maintain the client on bed rest until active labor begins. C. Insert an indwelling urinary catheter. D. Teach the client to hold their breath during contractions.

Correct Answer is A

Explanation

Choice A rationale

Assisting the client's partner to apply counterpressure to the sacrum can help alleviate the low-back pain associated with early labor by providing direct pressure to the area experiencing discomfort.

Choice B rationale

Maintaining the client on bed rest until active labor begins is not typically recommended, as mobility can help with the progression of labor and pain management.

Choice C rationale

Inserting an indwelling urinary catheter is not necessary for managing low-back pain in early labor and can increase the risk of infection and discomfort.

Choice D rationale

Teaching the client to hold their breath during contractions is not advisable, as it can lead to increased pain and decreased oxygenation for both the mother and baby. Breathing techniques are usually recommended to manage pain and ensure adequate oxygen delivery. .

A. Auscultate fetal heart tones during a contraction. B. Place a Doppler ultrasound over the fundus. C. Perform Leopold maneuvers to determine fetal position. D. Count the fetal heart rate for 15 seconds.

Correct Answer is C

Explanation

Choice A rationale

Auscultating fetal heart tones during a contraction does not provide a clear assessment of the fetal heart rate pattern and can be affected by the contraction itself.

Choice B rationale

Placing a Doppler ultrasound over the fundus is not effective, as the fundus is not the optimal location to hear fetal heart tones, especially in early labor.

Choice C rationale

Performing Leopold maneuvers to determine fetal position is crucial as it helps in placing the Doppler in the correct position for accurate monitoring of fetal heart tones.

Choice D rationale

Counting the fetal heart rate for 15 seconds and then multiplying by 4 may not provide an accurate assessment of the fetal heart rate pattern or variability, which is important for fetal well-being assessment. .

Free Nursing Test Bank

Correct Answer is A

Explanation

Correct Answer is C

Explanation

Quick Links

Resources

Free Nursing Test Bank

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?

Correct Answer is A

Explanation

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?

Correct Answer is C

Explanation

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 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 teaching with a client who is at 18 weeks of gestation and requires an increased intake of iron. Which of the following foods should the nurse recommend as the best source of iron?

A nurse is reinforcing discharge teaching about breastfeeding with a client. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is reinforcing teaching about outpatient resources for a client who is recovering from a molar pregnancy. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is caring for a client who asks about the purpose of a Papanicolaou test. Which of the following responses should the nurse make?

A nurse is assisting with the care of a client who is in active labor. The fetal monitor tracing shows late decelerations. Which of the following actions should the nurse take first?

Quick Links

Resources