Nokea
Select the 3 findings that require immediate follow-up.
- A. Lateral deviation of the uterus
- B. Deep tendon reflexes 1+
- C. Pain rating of 3 on a scale of 0 to 10 (increased)
- D. Peripheral edema 2+ bilateral lower extremities
- E. Uterine tone soft
- F. Large amount of lochia rubra
- G. Blood pressure 136/86 mm Hg
Correct Answer: A,B,C
Rationale: The correct answers are A, B, and C. A lateral deviation of the uterus could indicate a potential complication such as uterine inversion. Deep tendon reflexes being 1+ may suggest hyporeflexia, which could be a sign of neurological issues. A pain rating of 3 on a scale of 0 to 10, especially if increased, may indicate worsening pain that needs immediate attention. Choices D, E, F, and G do not require immediate follow-up as they are not indicative of urgent conditions. Peripheral edema 2+ bilateral lower extremities may be normal postpartum. Uterine tone being soft is expected in the postpartum period. A large amount of lochia rubra is typically seen in the immediate postpartum period. Blood pressure of 136/86 mm Hg is within normal limits for a postpartum patient.
You may also like to solve these questions
A nurse is reviewing the chart of a client who is 2 days postpartum following a vaginal delivery and reports constipation. Which of the following findings should the nurse identify as a contraindication to the use of a suppository?
- A. Vaginal candidiasis
- B. Abdominal distention
- C. Afterpains
- D. Third-degree perineal laceration
Correct Answer: D
Rationale: The correct answer is D: Third-degree perineal laceration. Using a suppository in a client with a third-degree perineal laceration can lead to further trauma and delayed wound healing. Suppositories are contraindicated in such cases to prevent infection and promote proper healing.
A: Vaginal candidiasis is not a contraindication for using a suppository, as it can actually help in treating the infection.
B: Abdominal distention would not necessarily contraindicate the use of a suppository.
C: Afterpains are common postpartum and do not specifically contraindicate the use of a suppository.
E, F, G: No other options provided.
A nurse in a provider’s office is caring for a 20-year-old client who is at 12 weeks of gestation and requests an amniocentesis to determine the sex of the fetus. Which of the following responses should the nurse make?
- A. You cannot have an amniocentesis until you are at least 35 years of age.
- B. This procedure determines if your baby has genetic or congenital disorders.
- C. Your provider will schedule a chorionic villus sampling to determine the sex of your baby.
- D. We can schedule the procedure for later today if you’d like.
Correct Answer: B
Rationale: The correct response is B: This procedure determines if your baby has genetic or congenital disorders. At 12 weeks of gestation, amniocentesis is typically done to assess genetic abnormalities, not to determine the sex of the fetus. Amniocentesis involves obtaining a sample of amniotic fluid to analyze the fetal cells for chromosomal abnormalities like Down syndrome. The procedure is not primarily used for determining the sex of the baby. The other options are incorrect for various reasons: A is inaccurate as there is no age requirement for amniocentesis; C is incorrect as chorionic villus sampling is another prenatal diagnostic test, not typically used to determine fetal sex; and D is inappropriate as scheduling a medical procedure without further assessment is not recommended.
A nurse is collecting data from a client who is at 30 weeks of gestation. Which of the following findings should the nurse identify as a manifestation of pyelonephritis?
- A. Epigastric discomfort
- B. Flank pain
- C. Temperature 37.7°C (99.8°F)
- D. Abdominal cramping
Correct Answer: B
Rationale: The correct answer is B: Flank pain. Pyelonephritis is an infection of the kidneys, commonly seen in pregnant women due to physiological changes. Flank pain is a classic symptom due to inflammation of the kidney tissue. Epigastric discomfort (A) is more indicative of gastrointestinal issues, not typically associated with pyelonephritis. Temperature elevation (C) is a common sign of infection but not specific to pyelonephritis. Abdominal cramping (D) is more commonly associated with uterine contractions in pregnancy.
A nurse is caring for a client who is at 37 weeks of gestation and is being tested for group B streptococcus ß-hemolytic (GBS). The client is multigravida and multipara with no history of GBS. She asks the nurse why the test was not conducted earlier in her pregnancy. Which of the following is an appropriate response by the nurse?
- A. You didn't report any symptoms of GBS during your pregnancy.'
- B. Your previous deliveries were all negative for GBS.'
- C. There was no indication of GBS in your earlier prenatal testing.'
- D. We need to know if you are positive for GBS at the time of delivery.'
Correct Answer: D
Rationale: The correct answer is D: We need to know if you are positive for GBS at the time of delivery. This is the most appropriate response because GBS status can change throughout pregnancy, and the risk of transmitting GBS to the newborn is highest during delivery. Testing closer to the due date ensures the most accurate results.
A: Incorrect. GBS may not present with symptoms, so relying on symptoms alone is not a reliable method for testing.
B: Incorrect. Previous negative results do not guarantee current status, as GBS status can change.
C: Incorrect. Lack of indication in earlier prenatal testing does not rule out GBS at the time of delivery.
E, F, G: Not provided, but unnecessary as the correct answer has been identified.
A nurse is admitting a client to the birthing unit who reports her contractions started 1 hr ago. The nurse determines the client is 80% effaced and 8 cm dilated. The nurse realizes that the client is at risk for which of the following conditions?
- A. Ectopic pregnancy
- B. Hyperemesis gravidarum
- C. Incompetent cervix
- D. Postpartum hemorrhage
Correct Answer: D
Rationale: The correct answer is D: Postpartum hemorrhage. The client being 80% effaced and 8 cm dilated indicates she is in active labor, which increases the risk of postpartum hemorrhage due to the rapid dilation of the cervix. As the cervix dilates, the blood vessels in the area are more prone to bleeding post-delivery. Ectopic pregnancy (A) occurs when the fertilized egg implants outside the uterus, which is not relevant in this scenario. Hyperemesis gravidarum (B) is severe nausea and vomiting during pregnancy, unrelated to the client's current condition. Incompetent cervix (C) is a condition where the cervix opens prematurely, typically in the second trimester, not during active labor.