A nurse is caring for a mother who delivered vaginally 2 hours ago.
Hemoglobin: 9 g/dL (11 to 14 g/dL). Hematocrit: 30% (36 to 43%). Platelets: 220,000/mm³ (150,000 to 400,000/mm³). WBC count: 12,000/mm³ (4,000 to 15,000/mm³). Temperature: 38.3°C (100.9°F). Select the 4 findings the nurse should report to the provider.
Respiratory assessment.
Hemoglobin level.
Heart rate.
Constant trickle of blood at the vagina.
Correct Answer : B,D
Choice A rationale
Respiratory assessment is important but not immediately concerning without specific abnormal findings.
Choice B rationale
Hemoglobin level of 9 g/dL is low and could indicate postpartum hemorrhage or anemia, warranting attention.
Choice C rationale
Heart rate abnormalities would be significant but are not provided in the data given.
Choice D rationale
Constant trickle of blood at the vagina suggests ongoing bleeding which could indicate a postpartum hemorrhage, requiring prompt intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
The Moro reflex is a startle response in newborns and does not assist in promoting latching during breastfeeding.
Choice B rationale
The stepping reflex, also known as the walking reflex, involves a newborn making stepping movements when held upright and does not contribute to latching during breastfeeding.
Choice C rationale
The rooting reflex causes a newborn to turn their head toward a touch on their cheek and begin sucking movements, which is crucial for promoting latching during breastfeeding.
Choice D rationale
The Babinski reflex involves the toes fanning out when the sole of the foot is stroked and is unrelated to latching during breastfeeding. .
Correct Answer is C
Explanation
Choice A rationale
Hypertonia, tachycardia, and metabolic alkalosis are not associated with necrotizing enterocolitis (NEC). NEC is characterized by gastrointestinal symptoms and signs of systemic illness.
Choice B rationale
Hypertension, apnea, and ruddy skin color are not specific indicators of necrotizing enterocolitis (NEC). NEC primarily presents with gastrointestinal symptoms and systemic instability.
Choice C rationale
Abdominal distention, temperature instability, and bloody stools are classic signs of necrotizing enterocolitis (NEC). These symptoms indicate severe inflammation and potential bowel necrosis.
Choice D rationale
Scaphoid abdomen, no residual with feedings, and increased urinary output are not characteristic of necrotizing enterocolitis (NEC). NEC typically presents with abdominal distention and feeding intolerance. .
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