A nurse is collecting data from a client who is 18 hr postpartum. Which of the following findings require the nurse to intervene?
Fundus located to right of umbilicus.
Temperature 37.8° C (100° F).
Deep tendon reflexes 2+.
Moderate amount of lochia rubra.
The Correct Answer is A
Choice A rationale
Fundus located to the right of the umbilicus requires intervention. This can indicate a full bladder, which can inhibit uterine contraction and increase the risk of postpartum hemorrhage.
Choice B rationale
A temperature of 37.8° C (100° F) is a common finding postpartum and usually does not require intervention unless it is accompanied by other signs of infection.
Choice C rationale
Deep tendon reflexes 2+ is a normal finding and does not require intervention. It indicates normal neuromuscular function.
Choice D rationale
A moderate amount of lochia rubra is expected postpartum and does not require intervention unless it is excessive or associated with other abnormal symptoms.
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View Related questions
Correct Answer is ["A","C","E"]
Explanation
Choice A rationale:
Breech presentation is a contraindication for dinoprostone as it increases the risk of complications during labor and delivery. Using dinoprostone to induce labor in a non-vertex presentation can lead to issues such as cord prolapse or obstructed labor, which necessitate a cesarean section for safe delivery.
Choice B rationale:
Terbutaline administration is used to manage preterm labor by relaxing the uterus. While it is relevant in labor management, it does not directly contraindicate the use of dinoprostone. Terbutaline and dinoprostone can be used in conjunction if properly managed.
Choice C rationale:
Fetal heart rate (FHR) monitoring showing abnormalities is a potential reason to withhold dinoprostone. Dinoprostone can increase uterine contractions, potentially stressing the fetus. A stable FHR with moderate variability indicates fetal well-being; however, if there were concerns, the provider might withhold dinoprostone.
Choice D rationale:
A WBC count of 9,500/mm³ is within the normal range and does not indicate an infection or condition that would contraindicate dinoprostone use. Elevated WBC count could raise concerns, but in this case, it is normal and not a contraindication.
Choice E rationale:
Lesions noted on the vaginal introitus and labia majora, likely caused by Herpes simplex virus, are a contraindication for dinoprostone. Active genital herpes lesions increase the risk of neonatal herpes transmission, making vaginal delivery risky. In such cases, cesarean delivery is often preferred to prevent transmission.
Correct Answer is ["B","F","G"]
Explanation
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.