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
Antibiotics should be taken for the full prescribed course, typically 10-14 days, to ensure complete resolution of the infection. Stopping antibiotics early can lead to recurrence or resistance.
Choice B rationale
Continuing to breastfeed while having mastitis is encouraged as it helps keep milk flowing and prevents blockage.
Choice C rationale
Taking analgesics for pain relief is appropriate during mastitis as it helps manage discomfort and supports continued breastfeeding.
Choice D rationale
Wearing a supportive bra helps alleviate discomfort and supports the breasts, which is beneficial during mastitis.
Correct Answer is A
Explanation
Choice A rationale: Heavy menstrual bleeding after an IUD insertion can be a sign of complications such as displacement of the IUD, infection, or other issues that require medical attention. It's important for the client to come to the clinic as soon as possible to be evaluated by a healthcare provider and ensure everything is functioning properly.
Choice B rationale: Taking her temperature every 4 hours is not directly relevant to the concern of heavy menstrual bleeding unless there is a suspicion of infection, which should still be evaluated in the clinic.
Choice C rationale: While some spotting or light bleeding can be normal after IUD insertion, heavy menstrual bleeding is not typical and should be assessed by a healthcare provider to rule out complications.
Choice D rationale: Advising the client to change her method of birth control without a proper evaluation is not appropriate. A healthcare provider should determine if the IUD is the right method for her or if there are any issues that need to be addressed.
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