A nurse is providing discharge teaching to a postpartum client.
The nurse emphasizes indications of potential complications and what to report to their provider.
Which of the following findings should the nurse teach the client as a sign of a complication and requires further evaluation by a healthcare provider?
Headache that is not relieved by hydration, rest or OTC medication.
Brownish red or pink lochia at 7 days postpartum.
Chills and fever greater than 100.4 F (38.0 C).
Feelings or thoughts of harming self or infant.
Increased urinary output.
Redness, pain or tenderness in calf.
Correct Answer : A,C,D
F.
Choice A rationale
A headache that is not relieved by hydration, rest, or over-the-counter medication can be a sign of postpartum preeclampsia, a serious condition that can occur after childbirth. Postpartum preeclampsia is characterized by high blood pressure and can lead to seizures, stroke, and other complications if not treated promptly.
Choice B rationale
Brownish red or pink lochia at 7 days postpartum is a normal finding. Lochia is the vaginal discharge that occurs after childbirth, and it typically changes color from bright red to pink or brownish red as the healing process progresses.
Choice C rationale
Chills and fever greater than 100.4°F (38.0°C) can indicate an infection, such as endometritis, which is an infection of the uterine lining. This condition requires prompt medical evaluation and treatment with antibiotics to prevent complications.
Choice D rationale
Feelings or thoughts of harming oneself or the infant are indicative of postpartum depression or postpartum psychosis, both of which are serious mental health conditions that require immediate attention and intervention from a healthcare provider.
Choice E rationale
Increased urinary output is a common postpartum finding as the body eliminates excess fluid retained during pregnancy. It is not typically a sign of a complication.
Choice F rationale
Redness, pain, or tenderness in the calf can be a sign of deep vein thrombosis (DVT), a blood clot that can occur in the legs. DVT is a serious condition that requires immediate medical evaluation and treatment to prevent the clot from traveling to the lungs and causing a pulmonary embolism.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Encouraging the client to empty her bladder is a common practice to prevent uterine atony and excessive bleeding. However, in this scenario, the fundus is already midline and firm at the umbilicus, indicating that the uterus is well-contracted. Therefore, this action is not necessary.
Choice B rationale
Notifying the client’s provider is not required in this situation. The findings of a light amount of lochia rubra and a firm, midline fundus are normal for 6 hours postpartum. There are no signs of complications that would necessitate contacting the provider.
Choice C rationale
Documenting the findings and continuing to monitor the client is the appropriate action. The client’s condition is stable, and the findings are within the expected range for 6 hours postpartum. Ongoing monitoring will ensure that any changes in the client’s condition are promptly addressed.
Choice D rationale
Increasing the frequency of fundal massage is not needed in this case. The fundus is already firm and midline, indicating that the uterus is well-contracted. Excessive fundal massage can cause discomfort and is unnecessary when the uterus is already in a good position.
Correct Answer is D
Explanation
Choice A rationale
Swelling in both breasts is more indicative of engorgement rather than mastitis. Mastitis typically affects only one breast.
Choice B rationale
A white patch on a nipple is more likely a sign of a yeast infection (thrush) rather than mastitis.
Choice C rationale
Cracked and bleeding nipples can be a risk factor for mastitis but are not a definitive sign of the condition.
Choice D rationale
A red and painful area in one breast is a classic sign of mastitis. This condition is often accompanied by flu-like symptoms such as fever and malaise.
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