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
Explanation
Choice A rationale
Frequent bowel movements help excrete bilirubin, which reduces jaundice. Newborns pass meconium and transitional stools frequently, aiding in bilirubin clearance.
Choice B rationale
A stable temperature is important for overall health, but it does not specifically impact bilirubin levels or jaundice.
Choice C rationale
A newborn should have 6-8 voids per day indicating good hydration, but it is not directly related to reducing jaundice.
Choice D rationale
A heel stick with a glucose level of 60 may indicate glucose monitoring but is not related to jaundice management.
Correct Answer is A
Explanation
Choice A rationale
Anticonvulsants can induce liver enzymes, increasing the metabolism of combined oral contraceptives (COCs) and reducing their effectiveness.
Choice B rationale
Antihypertensives do not have a significant impact on the effectiveness of COCs.
Choice C rationale
Antioxidants do not interfere with the metabolism or effectiveness of COCs.
Choice D rationale
Antibiotics, except for rifampin, typically do not reduce the effectiveness of COCs.
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