Testavia Free Nursing Practice Question - QA

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A nurse is assessing a client who is 4 hr postpartum following a vaginal delivery. Which of the following findings should the nurse identify as the priority?

A. Deep tendon reflexes 4+

Deep tendon reflexes that are 4+ indicate hyperreflexia, which can be a sign of preeclampsia or eclampsia. These conditions require immediate attention due to the risk they pose to both the client and the newborn. However, postpartum hemorrhage is a priority.

B. Fundus at level of umbilicus

The fundus should be firm and palpable at or just below the level of the umbilicus 4 hours postpartum. This finding suggests appropriate uterine involution. If the fundus is not well-contracted or if it is higher than expected, it could indicate uterine atony, which can lead to postpartum hemorrhage if not managed promptly. While important, this finding may not require immediate intervention unless there are signs of hemorrhage.

C. Saturated perineal pad in 30 min

A saturated perineal pad in 30 minutes suggests excessive postpartum bleeding, which is abnormal and could indicate postpartum hemorrhage. This finding requires immediate intervention to assess and manage the cause of bleeding, such as uterine atony, lacerations, or retained placental fragments.

D. Approximated edges of episiotomy

Approximated edges of an episiotomy indicate proper healing and would be expected 4 hours postpartum. While it is important to assess episiotomy healing, this finding does not typically require immediate intervention unless there are signs of infection or dehiscence.

This question is an excerpt from Testavia's nursing testbank - ATI NUR223absection 4 Maternity Final Exam. Take the full exam now

Full Explanation

C. A saturated perineal pad in 30 minutes suggests excessive postpartum bleeding, which is abnormal and could indicate postpartum hemorrhage. This finding requires immediate intervention to assess and manage the cause of bleeding, such as uterine atony, lacerations, or retained placental fragments.

A. Deep tendon reflexes that are 4+ indicate hyperreflexia, which can be a sign of preeclampsia or eclampsia. These conditions require immediate attention due to the risk they pose to both the client and the newborn. However, postpartum hemorrhage is a priority.

B. The fundus should be firm and palpable at or just below the level of the umbilicus 4 hours postpartum. This finding suggests appropriate uterine involution. If the fundus is not well-contracted or if it is higher than expected, it could indicate uterine atony, which can lead to postpartum hemorrhage if not managed promptly. While important, this finding may not require immediate intervention unless there are signs of hemorrhage.

D. Approximated edges of an episiotomy indicate proper healing and would be expected 4 hours postpartum. While it is important to assess episiotomy healing, this finding does not typically require immediate intervention unless there are signs of infection or dehiscence.

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