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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Correct Answer is D
Explanation
Choice A rationale
A maternal age of 30 years is not a significant risk factor for preeclampsia. Preeclampsia is more common in very young mothers or those over the age of 35.
Choice B rationale
A prepregnancy BMI of 19 is within the normal range and is not considered a risk factor for preeclampsia, which is more commonly associated with higher BMI or obesity.
Choice C rationale
Being in the third pregnancy (multiparity) is not a strong risk factor for preeclampsia. The risk factors are more closely related to the individual's health conditions and first pregnancies.
Choice D rationale
Chronic hypertension is a well-known risk factor for preeclampsia as it indicates pre-existing cardiovascular issues that can predispose one to developing preeclampsia during preg
Correct Answer is A
Explanation
Choice A rationale
"Decreased BP.”. This is correct because hyperemesis gravidarum can lead to dehydration, which in turn can cause hypotension (decreased blood pressure).
Choice B rationale
"WBC count 15,000/mm³ (5,000 to 15,000/mm³).”. This is incorrect because while WBC count can be elevated due to stress or infection, it is not a primary manifestation of hyperemesis gravidarum.
Choice C rationale
"Pruritus.”. This is incorrect because pruritus is not commonly associated with hyperemesis gravidarum. It is more likely related to other conditions like cholestasis of pregnancy.
Choice D rationale
"Hemoglobin 18 g/dL (11 to 16 g/dL).”. This is incorrect because an elevated hemoglobin level is not a direct manifestation of hyperemesis gravidarum, although dehydration can potentially concentrate blood components and slightly elevate hemoglobin.