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","C"]
Explanation
Choice A rationale
Apgar score assesses the newborn's health at 1 and 5 minutes post-delivery. A score of 8 at 1 minute and 10 at 5 minutes indicates good initial adaptation to extrauterine life.
Choice B rationale
Suctioning the mouth with a bulb syringe helps clear the airway of any meconium, which can be crucial to prevent respiratory complications.
Choice C rationale
Absence of visible meconium in the airway reduces the risk of meconium aspiration syndrome, a serious condition affecting the newborn's respiratory system.
Choice D rationale
Antibiotics are not routinely started after birth for all infants; they are used if there is a high risk or evidence of infection.
Correct Answer is D
Explanation
Choice A rationale
Platelets at 140,000 mg are within the normal range and are not typically indicative of postpartum complications like a thrombus.
Choice B rationale
Hemoglobin at 7 mg/dl indicates anemia but is not directly related to the symptoms of pain and tenderness in the calf.
Choice C rationale
A WBC count of 15,000 could indicate an infection or inflammatory process but is not specific to deep vein thrombosis (DVT).
Choice D rationale
Fibrinogen at 600 mg/dl is elevated and can be a marker for increased coagulation activity, which is associated with an increased risk of thrombosis. .
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