A nurse is caring for the client.
Select the 5 findings that indicate the client's condition has improved.
Heart rate
Temperature
Lochia
Hgb
WBC count
Fundal height
Correct Answer : A,B,C,E,F
A. Heart rate. The client’s heart rate decreased from 110/min on postpartum day 3 to 78/min on day 5, returning to normal resting range, which suggests improvement in systemic inflammation or infection, and better overall hemodynamic stability.
B. Temperature. The temperature has decreased from 38.6° C (101.5° F) to 37.1° C (98.9° F), which is within normal limits. This reduction is a key indicator of resolving infection or inflammation, especially considering the earlier febrile response.
C. Lochia. Lochia has improved from a moderate, foul-smelling, dark brown discharge to a small amount of brownish-red lochia with no odor, which suggests infection resolution and appropriate progression of postpartum uterine involution.
D. Hgb. The client’s hemoglobin dropped from 11.1 g/dL to 10 g/dL, which is below the normal postpartum range. This is likely due to ongoing recovery, recent surgery, and fluid shifts, but it does not indicate improvement and may require continued monitoring.
E. WBC count. The WBC count normalized from a significantly elevated 33,000/mm³ to 10,000/mm³, which is within the normal reference range. This is a strong sign that the infection or inflammatory response is resolving.
F. Fundal height. The fundus has decreased from 1 cm above the umbilicus on day 3 to 4 cm below on day 5, which is consistent with normal involution of the uterus during the postpartum period and is a positive sign of recovery.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Raise the head of the client's bed to a high-Fowler's position. A high-Fowler's position causes excessive hip flexion, which increases the risk of prosthetic dislocation after hip arthroplasty. Hip flexion should generally not exceed 90 degrees postoperatively.
B. Keep an abduction pillow between the client's legs. An abduction pillow maintains the leg in proper alignment and prevents internal rotation and adduction, which are common mechanisms of hip dislocation after surgery. It is a key intervention in protecting the surgical joint.
C. Elevate the client's affected leg on a pillow when in bed. Elevating the leg is appropriate for reducing swelling, but if not done correctly, it can cause improper hip positioning. It does not prevent dislocation unless combined with other alignment strategies.
D. Position the client's knees slightly higher than the hips when up in a chair. This position promotes hip flexion greater than 90 degrees, which increases the risk of dislocating the hip prosthesis. The hips should remain higher than the knees to prevent excessive flexion.
Correct Answer is A
Explanation
A. "Purchase a gift to give to your son from your baby." This is an effective strategy to help a young child feel included and valued, easing the transition and reducing potential jealousy. It fosters a positive emotional connection between the older sibling and the newborn.
B. "Make sure you are holding your baby when your son comes to visit you in the hospital." This may unintentionally make the child feel replaced or left out. It’s better for the parent to be free to hug and reassure the older child during the initial visit.
C. "Use medical terminology when teaching your son about your new baby." Medical terms may confuse or overwhelm a 4-year-old. Simple, age-appropriate language is more effective in helping the child understand the upcoming changes.
D. "Surprise your son with a new bedroom after you bring the baby home." Sudden changes can be disorienting or upsetting for young children. Involving them in the transition process before the baby arrives helps foster a sense of control and comfort.
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