A nurse is caring for a client who is 2 days postpartum. Which of the following findings should the nurse report to the provider?

4+ deep-tendon reflexes

Urine output 2.500 mL/day

Scant lochia rubra with a few small clots

Bilateral ankle edema

Answer and Explanation

The Correct Answer is A

A. 4+ deep-tendon reflexes: Deep-tendon reflexes are typically assessed using a scale ranging from 0 to 4+, with 4+ indicating hyperactive reflexes. In a postpartum client, hyperactive deep-tendon reflexes could indicate a potential complication such as preeclampsia or eclampsia, which require immediate medical attention. Therefore, the nurse should report this finding to the provider promptly.
B. Urine output 2,500 mL/day: A urine output of 2,500 mL/day is within the expected range for a postpartum client and does not require immediate intervention. Adequate urine output is important for assessing renal function and hydration status, but this finding does not indicate an urgent concern.
C. Scant lochia rubra with a few small clots: Scant lochia rubra with small clots is a normal finding in the early postpartum period. Lochia typically progresses from rubra (red) to serosa (pink) to alba (white) over time. As long as the lochia is not excessive or accompanied by large clots, this finding is not concerning and does not require immediate reporting to the provider.
D. Bilateral ankle edema: Mild bilateral ankle edema is common in the postpartum period and is often attributed to hormonal changes and shifts in fluid balance. While the nurse should continue to monitor for signs of worsening edema or other symptoms of preeclampsia, mild edema alone is not typically considered a critical finding requiring immediate reporting to the provider.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

A. Adding water to the formula will decrease its osmolarity, reducing the risk of hyperosmolar dehydration. This action helps to dilute the formula and make it more isotonic, which is better tolerated by the client's gastrointestinal tract.
B. Repositioning the NG tube may be necessary if there are issues with tube placement or if the tube has migrated. However, it is not directly related to addressing hyperosmolar dehydration.
C. Increasing the rate of formula delivery may exacerbate hyperosmolar dehydration by introducing more concentrated formula into the gastrointestinal tract, leading to further dehydration.
D. Switching to a lactose-free formula may be appropriate if the client has lactose intolerance, but it does not address the issue of hyperosmolar dehydration. Adding water to the formula is the more appropriate intervention in this scenario to decrease osmolarity and prevent dehydration.

A. Preeclampsia B. Transverse fetal lie C. Post-term pregnancy D. Intrauterine growth restriction

Correct Answer is B

Explanation

A. Preeclampsia: Preeclampsia is not a contraindication for the administration of misoprostol for induction of labor. In some cases, it may even be indicated to prevent complications associated with continuing the pregnancy.
B. Transverse fetal lie: A transverse fetal lie, where the baby is positioned sideways in the uterus, is a contraindication for the administration of misoprostol for induction of labor. Misoprostol is contraindicated when the fetal presentation is not cephalic (head down) due to the risk of complications, including cord prolapse.
C. Post-term pregnancy: Misoprostol is commonly used for induction of labor in post-term pregnancies, where the pregnancy has extended beyond 42 weeks. It helps initiate uterine contractions to stimulate labor and reduce the risk of complications associated with prolonged gestation.
D. Intrauterine growth restriction: Intrauterine growth restriction is not a contraindication for the administration of misoprostol for induction of labor. In such cases, the decision to induce labor would depend on various factors related to fetal well-being and maternal health.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is caring for a client who is 2 days postpartum. Which of the following findings should the nurse report to the provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is receiving enteral feedings via ah NG tube. The client has developed hyperosmolar dehydration. Which of the following actions should the nurse take when administering the client's feedings?

Correct Answer is A

Explanation

A nurse is reviewing the medical record of a client who has a prescription for misoprostol for induction of labor. Which of the following findings is a contraindication for administration of this medication?

Correct Answer is B

Explanation

A nurse is caring for a client who is preoperative for cataract removal. Which of the following statements by the client indicates an understanding of the procedure?

community health nurse is developing a plan of care for an older adult client who has type 2 diabetes mellitus and lives independently in a rural area. Which of the following interventions should the nurse include?

A nurse is assessing a child who is postoperative following a tonsillectomy. Which of the following findings should the nurse identify as the priority?

A nurse is caring for four children in an emergency department. Which of the following clients should the nurse assess first?

A nurse at a health department is providing anticipatory guidance to the parent of a 1-month-old infant. The nurse should inform the parent that the infant should receive which of the following immunizations at the age of 2 months?

A nurse is teaching a client who has generalized anxiety disorder about ways to help manage stress. Which of the following instructions should the nurse give the client about using progressive relaxation?

While a nurse is caring for a client who is receiving mechanical ventilation via an endotracheal tube, the high-pressure alarm on the ventilator sounds. Which of the following actions should the nurse take?

A nurse is caring for a client who has a new prescription for spironolactone and reports that they forgot to tell the provider that they take over- the-counter supplements. The nurse should instruct the client to avoid which of the following supplements?