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NurseDive Free Nursing Practice Question
Which physical assessment data should the nurse consider a normal finding for a primigravida client who is 12 hours postpartum?
A. Unilateral lower leg pain.
Unilateral lower leg pain:Unilateral lower leg pain can be a symptom of deep vein thrombosis (DVT), which is a serious condition. It requires further assessment and intervention.
B. Soft, spongy fundus
Soft, spongy fundus:A soft, spongy fundus is not a normal finding 12 hours postpartum. The fundus should be firm and well-contracted. A soft fundus could indicate uterine atony, a potential cause of postpartum hemorrhage.
C. Saturating two perineal pads per hour.
Saturating two perineal pads per hour: Saturating two perineal pads per hour is not a normal finding and may indicate excessive bleeding, which is concerning for postpartum hemorrhage. This requires immediate attention.
D. Pulse rate of 56 beats/minute
Pulse rate of 56 beats/minute:A pulse rate of 56 beats per minute can be within the normal range, especially if the client is at rest. However, it's essential to consider the overall clinical picture and whether there are any signs of distress or symptoms associated with a low pulse rate.
This question is an excerpt from Nurse Dive's nursing test bank - Samuel Merrit University Oaklands Hesi Maternity (Labor and Delivery) Proctored Exam. Take the full exam now
Full Explanation
A. Unilateral lower leg pain:
Unilateral lower leg pain can be a symptom of deep vein thrombosis (DVT), which is a serious condition. It requires further assessment and intervention.
B. Soft, spongy fundus:
A soft, spongy fundus is not a normal finding 12 hours postpartum. The fundus should be firm and well-contracted. A soft fundus could indicate uterine atony, a potential cause of postpartum hemorrhage.
C. Saturating two perineal pads per hour:
Saturating two perineal pads per hour is not a normal finding and may indicate excessive bleeding, which is concerning for postpartum hemorrhage. This requires immediate attention.
D. Pulse rate of 56 beats/minute:
A pulse rate of 56 beats per minute can be within the normal range, especially if the client is at rest. However, it's essential to consider the overall clinical picture and whether there are any signs of distress or symptoms associated with a low pulse rate.
Similar Questions
A client who is 32 weeks gestation comes to the women's health clinic and reports nausea and vomiting. On examination, the nurse notes that the client has an elevated blood pressure. Which action should the nurse implement next?
A. Inspect the client's face for edema
Inspect the client's face for edema: Elevated blood pressure during pregnancy may be a sign of preeclampsia, a condition that can involve fluid retention. Edema, particularly in the face, is one of the signs that the nurse should assess for in determining if preeclampsia is a concern.
B. Ascertain the frequency of headaches
Ascertain the frequency of headaches: Frequent headaches can be a symptom of various conditions, including preeclampsia. Gathering information about the frequency and characteristics of headaches can provide additional data for assessing the client's overall condition.
C. Evaluate for history of cluster headaches
Evaluate for history of cluster headaches: Cluster headaches, while severe, are not typically associated with elevated blood pressure during pregnancy. This information might not be directly relevant to the client's current symptoms.
D. Observe and time client's contractions
Observe and time client's contractions: Contractions are not typically associated with nausea, vomiting, or elevated blood pressure during pregnancy. This action may not address the primary concerns presented by the client.
Full Explanation
Inspect the client's face for edema:
Elevated blood pressure during pregnancy may be a sign of preeclampsia, a condition that can involve fluid retention. Edema, particularly in the face, is one of the signs that the nurse should assess for in determining if preeclampsia is a concern.
Ascertain the frequency of headaches:
Frequent headaches can be a symptom of various conditions, including preeclampsia. Gathering information about the frequency and characteristics of headaches can provide additional data for assessing the client's overall condition.
Evaluate for history of cluster headaches:
Cluster headaches, while severe, are not typically associated with elevated blood pressure during pregnancy. This information might not be directly relevant to the client's current symptoms.
Observe and time client's contractions:
Contractions are not typically associated with nausea, vomiting, or elevated blood pressure during pregnancy. This action may not address the primary concerns presented by the client.
A multiparous client with active herpes lesions is admitted to the unit with spontaneous rupture of membranes. Which action should the nurse take?
A. Prepare for a cesarean section
Prepare for a cesarean section:Active herpes lesions are a contraindication for vaginal delivery due to the risk of transmitting the herpes simplex virus (HSV) to the newborn. A cesarean section is necessary to prevent the baby from coming into direct contact with the herpes lesions and reduce the risk of neonatal herpes infection.
B. Cover the lesion with a dressing
Cover the lesion with a dressing:While covering the lesion might be part of overall care, it does not address the primary concern of preventing transmission to the newborn during delivery.
C. Obtain blood cultures
Obtain blood cultures: Obtaining blood cultures may not be the primary action in this situation. The concern is more related to preventing the transmission of the herpes virus to the newborn.
D. Administer penicillin.
Administer penicillin: Penicillin is not the treatment for herpes. Antiviral medications such as acyclovir are typically used for the treatment of herpes infections.
Full Explanation
Prepare for a cesarean section:Active herpes lesions are a contraindication for vaginal delivery due to the risk of transmitting the herpes simplex virus (HSV) to the newborn. A cesarean section is necessary to prevent the baby from coming into direct contact with the herpes lesions and reduce the risk of neonatal herpes infection.
Cover the lesion with a dressing:While covering the lesion might be part of overall care, it does not address the primary concern of preventing transmission to the newborn during delivery.
Obtain blood cultures:
Obtaining blood cultures may not be the primary action in this situation. The concern is more related to preventing the transmission of the herpes virus to the newborn.
Administer penicillin:
Penicillin is not the treatment for herpes. Antiviral medications such as acyclovir are typically used for the treatment of herpes infections.
A client at 18-weeks gestation was informed this morning that she has an elevated alpha-fetoprotein (AFP) level. After the healthcare provider leaves the room, the client asks what she should do next. What information should the nurse provide?
A. Discuss options for intrauterine surgical correction of congenital defects.
At this point, the AFP result is only an indicator, not a diagnosis. The client has not undergone sufficient diagnostic evaluation (such as ultrasound) to confirm any congenital defect that would warrant intrauterine surgery. Treatment options can only be discussed once a definitive diagnosis has been made.
B. Inform her that a repeat alpha-fetoprotein (AFP) should be evaluated.
While a repeat AFP test could be done in some cases to rule out lab error or confirm the result, this is not typically the immediate next step. An ultrasound provides more definitive and comprehensive information than simply repeating the AFP test.
C. Reassure the client that the AFP results are likely to be a false reading.
Reassure the client that the AFP results are likely to be a false reading: Providing false reassurance may lead to misunderstandings. While false positives can happen, it's crucial to follow up with further assessments to ensure the accuracy of the results.
D. Explain that a sonogram should be scheduled for definitive results
Explain that a sonogram should be scheduled for definitive results:An elevated AFP level is a screening test, not a definitive diagnosis. A sonogram (ultrasound) is the next step to obtain more detailed information about the fetus. Ultrasound can help assess for neural tube defects, confirm gestational age, and check for other anomalies that could explain the elevated AFP levels. This provides the most accurate and non-invasive method for evaluating potential fetal abnormalities.
Full Explanation
A. Discuss options for intrauterine surgical correction of congenital defects:At this point, the AFP result is only an indicator, not a diagnosis. The client has not undergone sufficient diagnostic evaluation (such as ultrasound) to confirm any congenital defect that would warrant intrauterine surgery. Treatment options can only be discussed once a definitive diagnosis has been made.
B. Inform her that a repeat alpha-fetoprotein (AFP) should be evaluated:While a repeat AFP test could be done in some cases to rule out lab error or confirm the result, this is not typically the immediate next step. An ultrasound provides more definitive and comprehensive information than simply repeating the AFP test.
C. Reassure the client that the AFP results are likely to be a false reading: Providing false reassurance may lead to misunderstandings. While false positives can happen, it's crucial to follow up with further assessments to ensure the accuracy of the results.
D. Explain that a sonogram should be scheduled for definitive results: An elevated AFP level is a screening test, not a definitive diagnosis. A sonogram (ultrasound) is the next step to obtain more detailed information about the fetus. Ultrasound can help assess for neural tube defects, confirm gestational age, and check for other anomalies that could explain the elevated AFP levels. This provides the most accurate and non-invasive method for evaluating potential fetal abnormalities.