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","E"]
Explanation
Choice A rationale
Douching is generally not recommended, especially during pregnancy, because it can disrupt the natural balance of bacteria in the vagina, potentially leading to infections or other complications.
Choice B rationale
Avoiding urination at bedtime is not advisable, as holding in urine can increase the risk of urinary tract infections (UTIs). Frequent urination is a good practice to help prevent and manage UTIs.
Choice C rationale
Wearing cotton-crotch underwear is recommended because cotton is breathable and helps to keep the genital area dry, reducing the risk of infections and irritation.
Choice D rationale
Eliminating yogurt products from the diet is not necessary; in fact, yogurt contains probiotics that can be beneficial for maintaining a healthy balance of bacteria in the gut and vaginal area.
Choice E rationale
Refraining from taking bubble baths is advised, as the chemicals in bubble bath products can irritate the urethra and increase the risk of UTIs.