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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is F
Explanation
Choice A rationale
Stools are a normal occurrence in newborns and are not typically associated with significant complications. The frequency and consistency can vary, but abnormal stools would not explain the given vital signs.
Choice B rationale
Temperature control is vital in newborns, but the given temperature is slightly low and alone does not indicate a specific complication without additional context such as infection or environment.
Choice C rationale
Feeding difficulties can occur in newborns, but they would typically present with symptoms related to weight and growth rather than the specific vital signs provided.
Choice D rationale
Extremities’ conditions, such as cyanosis or poor circulation, could indicate complications, but the given vital signs are not directly indicative of extremity problems.
Choice E rationale
Hypoglycemia in newborns can present with signs like jitteriness or lethargy, but it does not directly correlate with the provided vital signs without additional glucose measurements.
Choice F rationale
Neonatal Abstinence Syndrome (NAS) includes symptoms such as high heart rate, respiratory rate, and temperature instability, which align with the newborn's vital signs.
Correct Answer is D
Explanation
Choice B rationale: Prolactin is the hormone responsible for the production of breast milk. It does not determine the caloric content of the milk released later in the feeding.
Choice C rationale: Foremilk is the initial milk released during breastfeeding. It is higher in water content and lower in calories compared to hindmilk.
Choice D rationale: Hindmilk is the milk released later in the feeding. It is richer in fat and calories, providing essential nutrients and energy to the baby. The higher fat content in hindmilk helps in the baby's growth and development.
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