The nurse is preparing to care for a client in the immediate ...

[kodithompson]

The nurse is preparing to care for a client in the immediate postpartum period who has just delivered a healthy newborn. The nurse plans to take the client's vital signs every:
 
  1. Hour for the first 2 hours and then every 4 hours
  2. 15 minutes during the first hour and then every 30 minutes for the next
  2 hours
  3. 30 minutes during the first hour and then every hour for the next 2 hours
  4. 5 minutes for the first 30 minutes and then every hour for the next 4 hours

Question 2

The nurse is assisting in performing a physical assessment of a right-handed client's musculoskeletal system. Which of the following would be an abnormal finding?
 
  1. Presence of fasciculations
  2. Muscle strength of normal power
  3. Symmetrical movements bilaterally
  4. Hypertrophy of right upper arm of 1 cm

[prumorgan]

Answer to Question 1

2

Rationale: During the immediate postpartum period, vital signs are taken every 15 minutes in the first hour after birth, every 30 minutes for the next 2 hours, and every hour for the next 2 to 6 hours. Vital signs are monitored thereafter every 4 hours for 24 hours and every 8 to 12 hours for the remainder of the hospital stay.

Answer to Question 2

1

Rationale: Fasciculations are fine muscle twitches that are not normally present. Hypertrophy, or increased muscle size, on the client's dominant side of up to 1 cm is considered normal. Muscle strength is graded from (paralysis) to (normal power). Symmetrical muscle movement is a normal finding.