Difficulty: Medium
Average Score: 88%
Simulated
Passage / Scenario
A nurse is assessing a postpartum client who delivered vaginally 8 hr ago.Exhibit 1 - Nurses' Notes: 0700
Breasts soft, nipples intact. Uterus palpated firm, midline, and at the level of the umbilicus.
Moderate amount of lochia rubra. Episiotomy site well approximated with mild edema and
ecchymosis. Client reports pain as 2 on a scale of 0 to 10. Able to void spontaneously; no bladder
distention. Deep tendon reflexes 1+. Peripheral edema 2+ in bilateral lower extremities.
Exhibit 2 - Nurses' Notes: 1100
Breasts soft, nipples intact. Uterus palpated soft with lateral deviation and 1 cm above the
umbilicus. Large amount of lochia rubra. Episiotomy site well approximated with mild edema
and ecchymosis. Client reports pain as 3 on a scale of 0 to 10. Deep tendon reflexes 1+.
Peripheral edema 2+ in bilateral lower extremities.
Select the 3 findings that require immediate follow-up.
Correct answer
A,B,C
Rationale
The correct choices for immediate follow-up are A, B, and C. A lateral deviation of the uterus could indicate a possible complication like uterine atony or retained products of conception. Deep tendon reflexes of 1+ could suggest hyporeflexia or neurological issues. A pain rating of 3 on a scale of 0 to 10, especially if it has increased, may indicate worsening pain or a new issue. Choices D, E, F, and G do not present immediate concerns that require urgent follow-up compared to choices A, B, and C. Peripheral edema 2+ in bilateral lower extremities, soft uterine tone, large amount of lochia rubra, and a blood pressure of 136/86 mm Hg are important findings but do not necessitate immediate intervention or follow-up.