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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 C

Explanation

Choice A rationale

History of methicillin-resistant Staphylococcus aureus (MRSA) is not directly related to the use of a cervical cap. The main concern with a cervical cap is infection, but MRSA history alone doesn't make it a contraindication for this form of contraception.

Choice B rationale

History of thrombophlebitis is more of a concern with hormonal contraceptives due to the risk of blood clots. A cervical cap does not involve hormones, so this condition is not a direct contraindication.

Choice C rationale

History of toxic shock syndrome (TSS) is a contraindication for the use of a cervical cap because the cap can increase the risk of developing TSS again. TSS is associated with prolonged use of barrier contraceptives, which can create an environment that fosters the growth of bacteria responsible for TSS.

Choice D rationale

Type 1 diabetes mellitus is not a direct contraindication for the use of a cervical cap. The concern with diabetes is often related to blood glucose control and potential infections, but it doesn't specifically contraindicate the use of cervical caps.

Correct Answer is B

Explanation

Choice A rationale

Disabling the driver-side airbags is not advisable as airbags provide crucial protection in the event of a collision. Proper seating position is a safer alternative.

Choice B rationale

Moving the seat as far away as possible from the steering wheel reduces the risk of injury from airbag deployment and allows ample space for the growing abdomen, providing better safety for both mother and baby.

Choice C rationale

Wearing the lap belt high across the abdomen is incorrect and dangerous as it can cause injury to the fetus. The belt should be low across the hips.

Choice D rationale

Placing the shoulder harness across the gravid uterus is incorrect. The harness should go between the breasts and to the side of the belly, not across it, to avoid compression injuries in the event of a crash.

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