A nurse is caring for a postpartum client in an outpatient setting.
Nurses' Notes
Discharge from acute care facility note 2 days postpartum:
Client discharged to home with newborn. Fundus firm, midline, and measures two fingerbreadths below umbilicus. Lochia scant rubra. Episiotomy site well approximated. Mild labial edema present. Voiding without difficulty. Breastfeeding newborn every 2 to 3 hr. Denies any pain with breastfeeding, nipples intact. Reports increased firmness in breasts.
Outpatient setting notes 2 weeks postpartum:
Client seen for postdelivery check. Unable to palpate uterus. Denies abdominal pain. Reports perineal discomfort as 2 on a pain scale of 0 to 10. Small amount of whitish-yellow vaginal discharge. Continues to breastfeed. Verbalizes nipple discomfort throughout feeding. Visible crack noted on left nipple.
History and Physical
G1P1, spontaneous vaginal delivery with median episiotomy at 39 weeks of gestation. Newborn 4,508 g (9 lb 15 oz). APGARS: 8 at 1 min, 9 at 5 min.
Group B streptococcus B-hemolytic: positive (negative) Received 2 doses of intravenous penicillin G while in labor.
Complete the following sentence by using the lists of options.
The client is at highest risk for developing______evidenced by the client's______
The Correct Answer is ["mastitis","visible crack noted on left nipple"]
The client is at highest risk for developing mastitis evidenced by the client's visible crack noted on left nipple
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Incorrect. Bleeding gums can be a common finding during pregnancy due to hormonal changes, but they are not typically considered a serious concern unless severe.
B. Correct. Faintness upon rising can be a sign of orthostatic hypotension, which can be a concern during pregnancy and should be reported to the provider.
C. Incorrect. Mild swelling of the face can also occur during pregnancy, but significant or sudden swelling might be a sign of a condition like preeclampsia.
D. Incorrect. Urinary frequency is a common symptom of pregnancy due to increased pressure on the bladder from the growing uterus.
Correct Answer is C
Explanation
Based on the client's sudden right-sided numbness, weakness of the arm and leg, and distinct right-sided facial droop, the nurse should suspect a possible stroke and prioritize immediate interventions. After reporting the findings to the healthcare provider and receiving prescriptions, the nurse should implement the following intervention:
Notify the stroke team to assist with acute assessment and management. A stroke is a medical emergency that requires urgent intervention and specialized care. The stroke team is trained to quickly assess and manage stroke patients, including performing necessary diagnostic tests and initiating appropriate treatment. In this case, a STAT computerized tomography (CT) scan of the head has been ordered, indicating the need to evaluate the client's brain for possible ischemic or hemorrhagic stroke.
While keeping the bed in the lowest position and initiating seizure and fall precautions may be important considerations for stroke patients, notifying the stroke team takes precedence as they are specifically trained to manage acute stroke cases.
Administering aspirin to prevent further clot formation and platelet clumping is not appropriate without further assessment and confirmation of the type of stroke.
Additionally, testing for a swallowing reflex and performing communication deficit assessments can be important components of the overall stroke management plan, but they should be carried out by the stroke team or as directed by the healthcare provider.
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