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 B
Explanation
Choice A rationale
Bleeding gums can be common during pregnancy due to increased blood flow and hormonal changes that affect the gums, causing them to be more sensitive and prone to bleeding. It's usually not a cause for immediate concern unless it's severe or accompanied by other symptoms.
Choice B rationale
Abdominal cramping at 26 weeks of gestation could indicate preterm labor or other complications, such as placental abruption. It's a significant symptom that needs immediate medical attention to ensure both maternal and fetal well-being.
Choice C rationale
White vaginal discharge, known as leukorrhea, is common during pregnancy due to increased production of estrogen and greater blood flow to the vaginal area. It helps prevent infections and usually does not indicate a problem unless it has a foul odor or is accompanied by itching or irritation.
Choice D rationale
Asymptomatic palpitations are relatively common during pregnancy due to increased blood volume and changes in circulation. They usually don't indicate a serious problem unless they're severe, persistent, or accompanied by other symptoms like chest pain or shortness of breath.
Correct Answer is D
Explanation
Choice A rationale
Leukorrhea, a normal vaginal discharge, increases during pregnancy due to hormonal changes. It's not indicative of prenatal complications at 41 weeks of gestation.
Choice B rationale
Shortness of breath is common in late pregnancy due to the enlarged uterus pressing against the diaphragm. It is not necessarily a sign of a prenatal complication at this stage.
Choice C rationale
Non-pitting ankle edema is often seen in late pregnancy due to fluid retention and increased pressure on the veins. It is typically benign and not a sign of serious complications.
Choice D rationale
Blurred vision can indicate a serious prenatal complication such as preeclampsia, which is characterized by high blood pressure and can pose significant risks to both mother and baby if not managed properly. .