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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 D

Explanation

Choice A rationale

Mongolian spots are common, benign skin markings that some newborns have, but they are not related to rubella exposure during pregnancy.

Choice B rationale

Jaundice is a common condition in newborns, characterized by a yellowing of the skin and eyes, usually due to an immature liver. It's not specifically linked to maternal rubella exposure.

Choice C rationale

Transient strabismus, or temporary misalignment of the eyes, can occur in newborns but is unrelated to rubella. It usually resolves on its own as the newborn's muscles develop.

Choice D rationale

Deafness is a significant risk associated with congenital rubella syndrome. Rubella can damage the developing auditory system in utero, leading to permanent hearing loss in the newborn.

Correct Answer is ["C","E"]

Explanation

Choice A rationale

Douching is generally not recommended, especially during pregnancy, because it can disrupt the natural balance of bacteria in the vagina, potentially leading to infections or other complications.

Choice B rationale

Avoiding urination at bedtime is not advisable, as holding in urine can increase the risk of urinary tract infections (UTIs). Frequent urination is a good practice to help prevent and manage UTIs.

Choice C rationale

Wearing cotton-crotch underwear is recommended because cotton is breathable and helps to keep the genital area dry, reducing the risk of infections and irritation.

Choice D rationale

Eliminating yogurt products from the diet is not necessary; in fact, yogurt contains probiotics that can be beneficial for maintaining a healthy balance of bacteria in the gut and vaginal area.

Choice E rationale

Refraining from taking bubble baths is advised, as the chemicals in bubble bath products can irritate the urethra and increase the risk of UTIs.

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