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A nurse is collecting data from a client who is 18 hr postpartum. Which of the following findings require the nurse to intervene?

A.

Fundus located to right of umbilicus.

B.

Temperature 37.8° C (100° F).

C.

Deep tendon reflexes 2+.

D.

Moderate amount of lochia rubra.

Answer and Explanation

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 B

Explanation

Choice A rationale

Wearing an underwire bra is not recommended for clients with inverted nipples as it can cause discomfort and restrict milk flow. Proper support without constriction is essential.

Choice B rationale

Placing breast shells in the client's bra helps to draw out inverted nipples by applying gentle pressure, making breastfeeding easier. They also protect the nipples from friction and irritation.

Choice C rationale

Providing plastic-lined breast pads may prevent leakage, but they do not address the issue of inverted nipples. Proper nipple preparation is essential for effective breastfeeding.

Choice D rationale

Applying breast cream regularly might keep the skin hydrated, but it does not help to correct the inversion of the nipples. Mechanical aids like breast shells are more effective.

Correct Answer is C

Explanation

Choice A rationale

The newborn's legs flexing at the knees and hips when pressure is applied to the soles indicates the stepping reflex, an expected response.

Choice B rationale

Newborns do not typically keep their eyes closed when tapped on the forehead; this is not an expected reflex response.

Choice C rationale

The palmar grasp reflex, where the newborn's fingers curl around the nurse's finger, is an expected and normal finding in newborns, indicating healthy neurological function.

Choice D rationale

The rooting reflex, where the newborn turns their head when their cheek is touched, is expected and demonstrates feeding readiness and normal neural development. .

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