Level: Clinical
Difficulty: Medium
Subtopic: Postpartum assessment
NCLEX: A postpartum client on the mother-baby unit is being evaluated for immediate postpartum recovery. Assessment data…
Maternal-newborn nursing Health Promotion and Maintenance Reduction of Risk Potential
Case Study
A postpartum client on the mother-baby unit is being evaluated for immediate postpartum recovery. Assessment data include fundus boggy above the umbilicus and deviated to the right with heavy lochia. Which finding requires the nurse to intervene immediately?
Question
A. A stable, long-standing finding that matches the expected care plan.
B. A comfort request with unchanged vital signs and no new symptoms.
C. The new finding that fundus boggy above the umbilicus and deviated to the right with heavy lochia.
D. Routine data unchanged from the prior assessment.
B. A comfort request with unchanged vital signs and no new symptoms.
C. The new finding that fundus boggy above the umbilicus and deviated to the right with heavy lochia.
D. Routine data unchanged from the prior assessment.
Rationale
Correct answer: C. The new finding that fundus boggy above the umbilicus and deviated to the right with heavy lochia.
Rationale: Follow-up items test whether the nurse recognizes cues that are new, acute, or inconsistent with stability and need prompt nursing action.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Follow-up items test whether the nurse recognizes cues that are new, acute, or inconsistent with stability and need prompt nursing action.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.