A nurse is assessing a client who is 3 days postpartum.
Which of the following findings should the nurse report to the provider?
Heart rate 89/min.
BP 120/70 mm Hg.
Moderate lochia serosa.
Cool, clammy skin.
The Correct Answer is D
Choice A rationale
A heart rate of 89/min is within the normal range for adults, and would not typically be a cause for concern.
Choice B rationale
A blood pressure of 120/70 mm Hg is considered normal for adults.
Choice C rationale
Moderate lochia serosa is a normal part of the postpartum period.
Choice D rationale
This is the correct answer. Cool, clammy skin can be a sign of postpartum hemorrhage, a serious condition that requires immediate medical attention.
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Related Questions
Correct Answer is B
Explanation
Choice A rationale
While it’s important to monitor blood pressure in a client with peripartum cardiomyopathy, assessing it twice daily is not a specific intervention for this condition.
Choice B rationale
Restricting daily oral fluid intake is a key intervention in managing peripartum cardiomyopathy. This condition can lead to fluid overload, so limiting fluid intake can help prevent worsening of symptoms.
Choice C rationale
Misoprostol is a medication used to prevent stomach ulcers or to induce labor. It is not used in the management of peripartum cardiomyopathy.
Choice D rationale
Administering an IV bolus of lactated Ringer’s can increase the client’s fluid volume, which is not recommended in peripartum cardiomyopathy as it can exacerbate heart failure symptoms. Explore
Correct Answer is D
Explanation
The correct answer is choice d. The procedure is not necessary to determine the sex of the fetus.
Choice A rationale:
Chorionic villus sampling (CVS) is another prenatal test that can determine the sex of the fetus, but it is typically performed between 10-13 weeks of gestation. However, it is not the standard response to a request for amniocentesis.
Choice B rationale:
Age is not a criterion for performing an amniocentesis. This procedure can be done for various medical reasons regardless of the mother’s age.
Choice C rationale:
Scheduling an amniocentesis for the same day is not appropriate, especially since the primary purpose of amniocentesis is to diagnose genetic disorders, not to determine the sex of the fetus.
Choice D rationale:
This is the correct response because non-invasive methods like ultrasound can determine the sex of the fetus without the need for an invasive procedure like amniocentesis, which carries risks.
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