A nurse is caring for a mother who delivered vaginally 2 hr ago.
Heart rate 106/min.
Axillary temperature 36.6° C (98.0° F). Respiratory rate 22 /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
Abnormal respiratory assessment findings, such as increased respiratory rate or difficulty breathing, could indicate respiratory distress or infection and should be reported to the provider for immediate evaluation.
Choice B rationale
Hemoglobin level is a critical indicator of blood loss and overall oxygen-carrying capacity. A low level postpartum could suggest significant blood loss or anemia and requires reporting.
Choice C rationale
A heart rate of 106/min is higher than normal and could indicate underlying issues such as pain, anxiety, or hemorrhage. It should be reported to the provider for further assessment.
Choice D rationale
A constant trickle of blood at the vagina could indicate ongoing bleeding from a laceration or retained placental fragments, requiring immediate attention and intervention by the provider. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
Choice A rationale
A large ecchymotic caput succedaneum, which is swelling of the scalp due to birth trauma, usually resolves within a few days. However, its large size and presence of bruising should be monitored for potential complications such as jaundice.
Choice B rationale
Yellow discoloration of the sclera and oral mucosa indicates jaundice, which can be due to hyperbilirubinemia. This condition requires follow-up and possible treatment to prevent severe complications.
Choice C rationale
A level and soft fontanel in a newborn is a normal finding. It does not require follow-up as it indicates that intracranial pressure is normal.
Choice D rationale
A respiratory rate of 78/min in a newborn is significantly higher than the normal range (30-60/min). This finding requires follow-up to assess for respiratory distress or other underlying conditions.
Correct Answer is B
Explanation
Choice A rationale
Swelling of the labia postpartum can be a common occurrence due to trauma during delivery and does not specifically indicate the need to urinate. The swelling usually subsides with time and proper postpartum care.
Choice B rationale
A fundus positioned three fingerbreadths above the umbilicus can indicate a full bladder. The bladder's distension prevents the uterus from contracting properly, which can lead to postpartum hemorrhage and other complications, hence the need for the client to urinate.
Choice C rationale
Moderate lochia rubra is a normal finding in the postpartum period and does not specifically indicate the need to urinate. Lochia changes in color and amount over the postpartum weeks as the uterus heals.
Choice D rationale
Swelling of the ankles and feet, or edema, is common postpartum due to the body's adjustment to changes in blood volume and fluid shifts. It does not directly indicate the need to urinate.
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