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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 A

Explanation

Choice A rationale

Deep-vein thrombosis (DVT) is a contraindication for diaphragm use due to the increased risk of thromboembolic events with estrogen-based contraceptives.

Choice B rationale

Tobacco use, although a risk factor for cardiovascular disease, is not a direct contraindication for diaphragm use, which is a non-hormonal contraceptive method.

Choice C rationale

Recurrent urinary tract infections are a contraindication for diaphragm use due to the risk of infection exacerbation from device insertion.

Choice D rationale

History of positive group B streptococcus B-hemolytic is not a contraindication for diaphragm use; it typically relates to pregnancy and neonatal infection risk.

Correct Answer is B

Explanation

Choice A rationale

"Monitor perineal pads for clots.”. This is incorrect because while monitoring for clots is important, it does not address the underlying issue causing the fundal deviation.

Choice B rationale

"Assist the client to empty her bladder.”. This is correct because a full bladder can cause the uterus to deviate and impede uterine involution. Emptying the bladder helps the uterus to contract properly and return to its normal position.

Choice C rationale

"Notify the provider.”. This is incorrect because the immediate action should be to address the potential cause of the deviation (a full bladder), which can be managed by the nurse.

Choice D rationale

"Administer a prescribed analgesic.”. This is incorrect because administering pain relief does not address the cause of the fundal deviation and does not alleviate the potential issue.

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