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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

The newborn's legs flexing at the knees and hips when pressure is applied to the soles indicates the stepping reflex, an expected response.

Choice B rationale

Newborns do not typically keep their eyes closed when tapped on the forehead; this is not an expected reflex response.

Choice C rationale

The palmar grasp reflex, where the newborn's fingers curl around the nurse's finger, is an expected and normal finding in newborns, indicating healthy neurological function.

Choice D rationale

The rooting reflex, where the newborn turns their head when their cheek is touched, is expected and demonstrates feeding readiness and normal neural development. .

Correct Answer is D

Explanation

Choice A rationale

This statement is incorrect because a Papanicolaou test, or Pap smear, is not used for the removal of uterine fibroids. Fibroid removal typically involves surgical procedures like myomectomy.

Choice B rationale

This statement is incorrect because a Pap smear is not used to determine ovulation status. Ovulation can be monitored through methods like basal body temperature tracking or hormone assays.

Choice C rationale

This statement is incorrect because a Pap smear does not detect endometriosis. Endometriosis is usually diagnosed through laparoscopy or imaging studies like ultrasound or MRI.

Choice D rationale

This statement is correct because a Papanicolaou test is specifically designed to detect the presence of cervical cancer and precancerous changes in the cervical cells.

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