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. .
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Drying and covering the infant helps prevent heat loss and maintain body temperature, which is essential for newborns immediately after birth.
Choice B rationale
Stimulating the infant to cry helps clear the airways but is usually done after ensuring the respiratory tract is clear.
Choice C rationale
Clearing the respiratory tract is the priority immediately after birth to ensure the newborn can breathe properly and reduce the risk of aspiration.
Choice D rationale
Assessing the umbilical cord is important but not the first priority. Ensuring the airway is clear takes precedence to establish effective breathing. .
Correct Answer is B
Explanation
Choice A rationale
The Apgar score includes five criteria: heart rate, respiratory effort, muscle tone, reflex irritability, and color. Heart rate 60 scores 1, weak cry scores 1, partial flexion of extremities scores 1, weak suck scores 1, gray color scores 0. Total score: 4.
Choice B rationale
The Apgar score includes five criteria: heart rate, respiratory effort, muscle tone, reflex irritability, and color. Heart rate 60 scores 1, weak cry scores 1, partial flexion of extremities scores 1, weak suck scores 1, gray color scores 0. Total score: 4.
Choice C rationale
The Apgar score includes five criteria: heart rate, respiratory effort, muscle tone, reflex irritability, and color. Heart rate 60 scores 1, weak cry scores 1, partial flexion of extremities scores 1, weak suck scores 1, gray color scores 0. Total score: 4.
Choice D rationale
The Apgar score includes five criteria: heart rate, respiratory effort, muscle tone, reflex irritability, and color. Heart rate 60 scores 1, weak cry scores 1, partial flexion of extremities scores 1, weak suck scores 1, gray color scores 0. Total score: 4.
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