Difficulty: Medium
Average Score: 68%
Simulated
Passage / Scenario
A nurse is assessing a postpartum client who delivered vaginally 8 hr ago. Nurses' Notes: 0700: Breasts soft, nipples intact. Uterus firm, midline, at umbilicus. Moderate lochia rubra. Episiotomy well approximated, mild edema, ecchymosis. Pain 2/10. Able to void, no bladder distention. DTR 1+. Peripheral edema 2+ in legs. 1100: Breasts soft, nipples intact. Uterus soft, laterally deviated, 1 cm above umbilicus. Large lochia rubra. Pain 3/10. DTR 1+. Peripheral edema 2+ in legs. Vital Signs: 0700: Temp 36.2°C, Pulse 80/min, RR 16/min, BP 136/82 mmHg, SpO2 99%. 1100: Temp 37.2°C, Pulse 85/min, RR 18/min, BP 136/86 mmHg, SpO2 100%.Select the 3 findings that require immediate follow-up.
Correct answer
A, D, G
Rationale
A soft uterus (A) risks postpartum hemorrhage. Large lochia rubra (D) may indicate bleeding issues. Lateral uterine deviation (G) suggests a full bladder or complication. BP, edema, pain, and soft breasts are within normal limits.