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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
While assessing the client’s kidney function is important in general, it is not the best way to evaluate medication adherence. Kidney function can affect the metabolism and excretion of medications, but it does not directly indicate whether the client is taking their medication as prescribed.
Choice B rationale
Correct answer. Checking the client’s serum medication level is the most direct and reliable way to evaluate medication adherence. If the client is taking the medication as prescribed, the serum medication level should be within the therapeutic range.
Choice C rationale
Determining the client’s apical pulse rate can provide information about the client’s overall cardiovascular status and can indicate certain drug effects or side effects, but it does not directly measure medication adherence.
Choice D rationale
Asking the client if they are taking the medication as prescribed can provide useful information, but it relies on self-report, which may not be reliable. Some clients might forget doses or not take the medication exactly as prescribed.
Correct Answer is D
Explanation
Choice A rationale
The weight of the newborn is not a factor in the decision to delay the instillation of antibiotic ophthalmic ointment. The ointment is used to prevent eye infections caused by bacteria present in the mother’s birth canal, and this risk is not related to the newborn’s weight.
Choice B rationale
Whether the newborn was delivered via cesarean birth or vaginal birth does not affect the decision to delay the instillation of antibiotic ophthalmic ointment. The ointment is used to prevent eye infections that can occur regardless of the method of delivery.
Choice C rationale
While it is important to monitor newborns for signs of infection, delaying the instillation of antibiotic ophthalmic ointment would not aid in identifying manifestations of infection. The ointment is a preventative measure and does not interfere with the observation of symptoms.
Choice D rationale
Correct answer. The instillation of antibiotic ophthalmic ointment can cause blurred vision in the newborn. Delaying the instillation of the ointment facilitates immediate bonding between the newborn and parent, as the newborn will be able to see more clearly.
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