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
Explanation
Choice A rationale
Amniocentesis is used to detect fetal genetic abnormalities, such as Down syndrome, by analyzing the amniotic fluid for genetic markers.
Choice B rationale
An empty bladder is required for the test only in late pregnancy to prevent bladder injury; however, in early pregnancy, a full bladder may be required to better visualize the uterus and amniotic fluid.
Choice C rationale
An x-ray is not typically used during the needle placement for amniocentesis. Ultrasound is the preferred method to guide the needle to avoid harm to the fetus and mother.
Choice D rationale
The test does not determine the volume of amniotic fluid; it is used primarily for genetic analysis, assessing fetal lung maturity, and diagnosing certain fetal infections.
Correct Answer is B
Explanation
Choice A rationale
Securing a clean diaper snugly across the newborn's penis might help manage minor bleeding but won't effectively address active oozing of bright red blood from a circumcision site.
Choice B rationale
Applying gentle pressure using a sterile dry gauze pad is the appropriate action to control bleeding. Applying direct pressure helps to stop the bleeding and allows for proper assessment of the wound.
Choice C rationale
Rinsing the newborn's penis with cool water might provide temporary relief but is not an effective method to control bleeding from a surgical site. It may also increase the risk of infection if not done sterilely.
Choice D rationale
Placing petroleum jelly on the bleeding site is typically done to prevent the diaper from sticking to the incision, but it is not sufficient to control active bleeding. .