A nurse is completing a postpartum assessment. Which finding would alert the nurse to a potential problem?

temperature of 101° F (38.3° C)

respiratory rate of 16 breaths per minute

lochia rubra with a fleshy odor

pain rating of 2 on a scale from 0 to 10

Answer and Explanation

The Correct Answer is A

A. Temperature of 101° F (38.3° C) is concerning as it may indicate an infection, especially if it persists beyond the first 24 hours postpartum. A mild increase in temperature can be common during the first 24 hours after birth due to the physical stress of labor and delivery, but a temperature of 101° F is above the normal postpartum range and warrants further investigation for possible infection, such as endometritis or a urinary tract infection.

B. Respiratory rate of 16 breaths per minute is within the normal range for a postpartum woman, as normal respiratory rate is typically between 12 and 20 breaths per minute in adults. No immediate concerns are suggested by this finding.

C. Lochia rubra with a fleshy odor is a normal finding during the first few days postpartum. Lochia rubra, the initial discharge after childbirth, typically has a fleshy or musty odor and contains blood, mucus, and tissue from the uterine lining. A foul or offensive odor, however, would be indicative of infection, but a "fleshy" odor is normal.

D. Pain rating of 2 on a scale from 0 to 10 is within an acceptable range for postpartum pain. Mild discomfort is expected, especially around the perineum or from uterine contractions, and can usually be managed with over-the-counter pain relievers. A pain level of 2 suggests that the patient is coping well.

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Correct Answer is C

Explanation

A. Fluid replacement is important for maintaining maternal and fetal circulation, but it is not the priority immediately following a seizure. Oxygenation and stabilizing the mother’s condition are more critical in the acute phase.

B. Birth of the fetus may become necessary if the mother’s condition worsens, but the immediate priority is stabilizing the mother and ensuring proper oxygenation to prevent further complications for both the mother and fetus.

C. Oxygenation is the priority intervention after a seizure in eclampsia. Seizures can lead to a decrease in oxygen levels, and ensuring adequate oxygenation is crucial for both the mother and fetus. The nurse should administer oxygen to support breathing and prevent hypoxia.

D. Control of hypertension is essential in managing eclampsia, but the immediate focus should be on stabilizing the mother post-seizure, which includes ensuring adequate oxygenation first. Once stabilized, antihypertensive medications can be administered as necessary.

A. 0.75ml B. 15ml C. 1.5 ml D. 0.9ml

Correct Answer is C

Explanation

A. 0.75 mL would provide only 1.5 mg, which is half the prescribed dose
B. 15 mL would provide 30 mg, which is ten times the prescribed dose and could be dangerously toxic
C. 1.5 mL is correct and delivers exactly 3 mg of Stadol, matching the provider's order. To calculate the correct volume to administer, use the formula: Dose to give= ordered dose/concentration= 3/2= 1.5ml
D. 0.9 mL would give 1.8 mg, which is below the ordered dose.

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A nurse is completing a postpartum assessment. Which finding would alert the nurse to a potential problem?

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Naxlex Comprehensive Predictor Exams

A woman with gestational hypertension develops eclampsia and experiences a seizure. Which intervention would the nurse identify as the priority?

Correct Answer is C

Explanation

The nurse is caring for a client in labor who has refused epidural anesthesia. An order was placed for Stadol 3mg IV Q4h PRN pain. The drug is supplied 2 mg per ml. How much of the medication should the nurse give?

Correct Answer is C

Explanation

A nurse is completing a postpartum assessment. Which finding would alert the nurse to a potential problem?

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