A nurse is caring for a client who is 2 days postpartum. Which of the following findings should the nurse report to the provider?
Scant lochia rubra with a few small clots
Urine output 2,500 mL/day
Bilateral ankle edema
4+ deep-tendon reflexes
The Correct Answer is D
A. Scant lochia rubra with a few small clots. Lochia rubra is expected in the early postpartum period, and small clots are normal unless excessive bleeding occurs.
B. Urine output 2,500 mL/day. Increased urine output is expected postpartum as the body eliminates excess fluid retained during pregnancy.
C. Bilateral ankle edema. Mild edema is common postpartum due to fluid shifts and typically resolves on its own.
D. 4+ deep-tendon reflexes. Hyperreflexia is a sign of central nervous system irritability and may indicate preeclampsia, which requires immediate evaluation.
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Correct Answer is D
Explanation
A. Cataract surgery is typically performed under local anesthesia with sedation, not general anesthesia.
B. Seeing dark spots is not a common or expected outcome. Some clients may experience temporary blurriness, but not dark spots.
C. Bruising of the eyelids is not a typical side effect of cataract removal. There may be mild swelling or redness, but significant bruising is unusual.
D. Cataract removal involves removing the cloudy lens and replacing it with an artificial intraocular lens (IOL) to restore clear vision. This statement shows the client understands the procedure.
Correct Answer is D
Explanation
A. "You can take this medication with milk." This is incorrect because dairy products interfere with the absorption of tetracycline and should be avoided when taking the medication.
B. "You should take this medication at bedtime." This is incorrect because taking tetracycline at bedtime increases the risk of esophageal irritation. It should be taken with a full glass of water while sitting or standing upright.
C. "Constipation is an adverse effect of this medication." This is incorrect because tetracycline is more commonly associated with diarrhea rather than constipation.
D. "Light sensitivity is an adverse effect of this medication." This is correct because tetracycline can cause photosensitivity, making the skin more susceptible to sunburn. Clients should be advised to use sunscreen and wear protective clothing when exposed to sunlight.
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