A nurse is caring for a mother who delivered vaginally 2 hr ago.
Axillary temperature 36.6° C (98.0° F). Heart rate 110/min.
Respiratory rate 24/min.
Oxygen saturation 94%. 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 crucial postpartum, especially with an elevated respiratory rate. It helps detect any respiratory distress or complications early.
Choice B rationale
Hemoglobin level assessment is essential to identify anemia or excessive blood loss during delivery, which can compromise the mother's health.
Choice C rationale
A heart rate of 110/min is above the normal range and might indicate tachycardia, which requires monitoring and possibly intervention.
Choice D rationale
A constant trickle of blood at the vagina could indicate postpartum hemorrhage, necessitating immediate medical attention.
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Related Questions
Correct Answer is ["A","B","C","D"]
Explanation
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.
Correct Answer is B
Explanation
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