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 A
Explanation
Choice A rationale
Testing for GBS at around 36 weeks of gestation is standard practice to identify carriers and prevent neonatal GBS infections through intrapartum antibiotic prophylaxis if necessary.
Choice B rationale
Cesarean birth is not indicated solely based on a positive GBS status. The primary intervention is intrapartum antibiotic prophylaxis to reduce the risk of neonatal infection.
Choice C rationale
Routine antibiotic administration during the last weeks of pregnancy is not standard practice; antibiotics are given during labor if GBS is present to prevent transmission to the baby.
Choice D rationale
GBS infection does not cause hearing loss in newborns. The primary concern is neonatal sepsis, pneumonia, or meningitis, not hearing loss.
Correct Answer is C
Explanation
Choice A rationale
Maternal age of 21 years is not considered a significant risk factor for gestational diabetes. Typically, advanced maternal age (35 years or older) is considered a risk factor due to changes in insulin resistance that occur with age.
Choice B rationale
A fasting blood glucose of 72 mg/dL is within the normal range and does not indicate a risk for gestational diabetes. Gestational diabetes is usually diagnosed with fasting blood glucose levels higher than 95 mg/dL.
Choice C rationale
Previous newborn weighing 4.8 kg is a significant risk factor for gestational diabetes. Having a macrosomic (large) baby in a previous pregnancy is linked with an increased risk of developing gestational diabetes in subsequent pregnancies.
Choice D rationale
A prepregnancy BMI of 23 is within the normal range (18.5-24.9) and does not increase the risk of gestational diabetes. Higher BMI levels, particularly above 25, are associated with an increased risk.