A nurse is caring for a mother who delivered vaginally 2 hr ago. 38 week gestation.Vaginal delivery of a 9-pound 8-ounce baby girl.
Select the 4 findings the nurse should report to the provider.
Respiratory assessment.
Hemoglobin level.
Heart rate.
Constant trickle of blood at vagina.
Correct Answer : A,B,C,D
Choice A rationale
Respiratory assessment is vital, especially following childbirth, to ensure the mother is not experiencing respiratory issues.
Choice B rationale
Monitoring hemoglobin levels can help identify significant blood loss during delivery, which can lead to anemia and other complications.
Choice C rationale
A heart rate that is elevated postpartum may indicate underlying issues such as infection or hemorrhage, which need to be reported.
Choice D rationale
Continuous blood trickling from the vagina is a warning sign of potential postpartum hemorrhage, which is a medical emergency.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["0.8"]
Explanation
Step 1 is 0.2 mg × 4 doses = 0.8 mg
The total amount the patient will receive in a 24-hour period is 0.8 mg.
Correct Answer is ["C","D","E"]
Explanation
Choice A rationale
A fundus midline and firm at the umbilicus is a normal postpartum finding and does not require reporting. It indicates that the uterus is contracting as expected to prevent postpartum hemorrhage.
Choice B rationale
Moderate lochia rubra without clots is expected in the immediate postpartum period and does not need to be reported. It is part of normal postpartum bleeding as the uterus sheds its lining.
Choice C rationale
A constant trickle of blood at the vagina postpartum could indicate a laceration or retained placental fragments and should be reported to the provider for further evaluation and management.
Choice D rationale
Hemoglobin levels can provide important information about the mother's blood loss during delivery. A low hemoglobin level could indicate significant blood loss and necessitates reporting.
Choice E rationale
An abnormal heart rate in a postpartum mother could be indicative of complications such as hemorrhage or infection and should be reported to the provider for further assessment.
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