Pre-Test 1 and 2: Introduction to Special Questions Based on Official NCLEX-RN[®]
16. A client, who is 17 years old, has delivered a 6-pound, 6-ounce girl at 38 weeks' gestation 3 hours ago. A nurse is completing a routine postpartum assessment. Which assessments should the nurse report to a physician immediately? Select all that apply.
. Positive Homans' sign.
. 2+ deep tendon reflexes.
. Moderate rubra lochia.
. Expression of orange-sized clots during fundal massage.
. Fundus palpable firm at the level of the umbilicus.
Test-Taking Tip
When a question asks what should be reported immediately, think of the possible life-threatening client outcome if a situation is not reported to the physician.
Content Area: Maternity, Postpartum; Integrated Process: Nursing Process, Assessment; Cognitive Level: Analysis; Client Need/Subneed: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems
Pre-Test 1 and 2: Introduction to Special Questions Based on Official NCLEX-RN[®]
. .
Answer 1 is correct because a positive Homans' sign can be a symptom of deep vein thrombosis and needs to be reported to the physician immediately. Answer 2 is incorrect because 2+ deep tendon reflexes are a normal finding, and do not need to be reported to the physician. Deep tendon reflexes that are a 3+ or 4+ may indicate cerebral irritability from preeclampsia and should be reported to the physician. Answer 3 is incorrect because moderate rubra lochia is a normal finding 3 hours after delivery, and does not need to be reported to the physician. Large rubra lochia or expulsion of blood clots during fundal massage would indicate a postpartum hemorrhage and should be reported to the physician. Answer 4 is correct because expression of orange-sized clots during fundal massage is a sign of postpartum hemorrhage and should be reported to the physician immediately. Answer 5 is incorrect because a fundus that is palpable firm at the level of the umbilicus is a normal finding 3 hours after delivery and does not need to be reported to the physician. A fundus that is deviated from the midline or palpable above the umbilicus is not a normal finding, and should be reported to the physician