A nurse is caring for a client who is 24 hr postpartum. Which of the following findings should the nurse report to the provider?
WBC count 12,000/mm3 (5,000 to 10,000/mm3)
Temperature 37.8° C (100° F)
Respiratory rate 16/min
Hgb 8 g/dL (less than 11 g/dL)
The Correct Answer is D
A. WBC count 12,000/mm³: A mild elevation in white blood cell count is expected within the first few days postpartum as part of the normal inflammatory response due to the stress of labor and delivery.. A count of 12,000/mm³ is not alarming and does not necessarily indicate infection or a complication.
B. Temperature 37.8°C (100°F): A low-grade temperature elevation within the first 24 hours postpartum is common due to hormonal shifts, dehydration, or exertion from labor. This finding would not immediately require provider notification unless it persists or rises higher.
C. Respiratory rate 16/min: A respiratory rate of 16 breaths per minute is within normal adult limits and does not suggest respiratory distress or any postpartum complication, so no intervention is required for this finding.
D. Hgb 8 g/dL: A hemoglobin level of 8 g/dL is significantly low and can indicate postpartum hemorrhage or significant blood loss. This degree of anemia should be reported promptly to the provider to assess the need for interventions such as blood transfusion or iron supplementation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D","E"]
Explanation
- Initiate a power of attorney for health care document: Nurses do not initiate or create legal documents like a power of attorney. The client must initiate this, often with legal assistance if needed.
- Provide the client with written information about advance directives: It is the nurse’s responsibility to ensure the client receives clear, written information about advance directives, including explanations of living wills, DNR orders, and medical power of attorney documents.
- Instruct the client that an advance directive is a legal document and must be honored by care providers: Nurses reinforce that advance directives are legally binding documents. They ensure the client's wishes are respected by the healthcare team throughout their care.
- Communicate advance directives status via the medical record and shift report: Once a client’s advance directive status is known, it must be accurately documented and communicated to all healthcare providers to ensure continuity and adherence to the client’s wishes.
- Document that the provider discussed do-not-resuscitate status with the client: Nurses are responsible for documenting that the conversation regarding DNR status occurred, including who had the conversation and the client's stated wishes, even though the actual discussion is led by the provider.
- Inform the client that an advance directive discontinues further care: Advance directives do not mean that all care is discontinued. Clients can still receive comfort, palliative, or supportive treatments based on their wishes outlined in the directive.
Correct Answer is D
Explanation
A. Provide the client with low-calorie formula: The calorie content of the formula is not typically responsible for diarrhea. Diarrhea is more often related to formula intolerance, contamination, or rapid feeding rates rather than calorie density.
B. Increase the rate of the client's feeding: Increasing the rate can worsen diarrhea by overwhelming the gastrointestinal system, leading to poor absorption and increased fluid loss. Slower rates are often needed if diarrhea occurs.
C. Switch the client to a formula containing less protein: Protein content is usually not the cause of diarrhea. Specialized formulas may be needed for certain conditions, but protein itself is not typically a trigger for diarrhea.
D. Administer the client's formula at room temperature: Cold formula can cause gastric cramping and diarrhea. Administering the formula at room temperature helps reduce gastrointestinal irritation and promotes better tolerance of the feeding.
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