A nurse on the postpartum unit is caring for four clients. For which of the following clients should the nurse notify the provider?
A client who reports luchia rubra requiring changing perineal pads every 3 hr
A client who has a urinary output of 300 mL in 8 hr
A client who is receiving magnesium sulphate and has absent deep tendon reflexes
A client who reports abdominal cramping during breastfeeding
The Correct Answer is C
A. A client who reports lochia rubra requiring changing perineal pads every 3 hr: Lochia rubra is the normal discharge during the early postpartum period. Changing perineal pads every 3 hours is within the expected range and does not warrant immediate notification of the provider.
B. A client who has a urinary output of 300 mL in 8 hr: Although the urinary output is relatively low, the information provided is not sufficient to conclude that this is abnormal. Further assessment is needed, and this finding alone may not be an emergency. However, it should be monitored.
C. A client who is receiving magnesium sulfate and has absent deep tendon reflexes: Absent deep tendon reflexes can be a sign of magnesium toxicity. Magnesium sulfate is used for various indications, such as preeclampsia or eclampsia, but it has a narrow therapeutic range. Absent deep tendon reflexes suggest the need for immediate attention and notification of the provider.
D. A client who reports abdominal cramping during breastfeeding: Abdominal cramping during breastfeeding is a common postpartum symptom associated with uterine contractions. It is a normal physiological response and does not require immediate notification of the provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Hypnosis can be beneficial if you practiced it during the prenatal period
Hypnosis techniques for pain management during labor can indeed be effective if practiced and learned before the onset of labor. Practicing hypnosis techniques during the prenatal period allows the individual to become more familiar with the process, enhancing their ability to use hypnosis as a pain management tool during labor.
B. Hypnosis does not work for controlling pain associated with labor: This statement is inaccurate. While hypnosis might not be effective for everyone, it can be a beneficial technique for managing labor pain in some individuals. It's important not to dismiss its potential efficacy for pain control in labor.
C. Synchronized breathing will be required during hypnosis: While breathing techniques are often incorporated into various pain management strategies during labor, such as in childbirth education classes or relaxation techniques, the requirement for synchronized breathing specifically during hypnosis is not universally accurate. Hypnosis techniques can vary, and they might or might not involve synchronized breathing.
D. Focusing on controlling body functions will be helpful during hypnosis: Hypnosis typically involves relaxation and focus but not necessarily the conscious control of body functions. The emphasis in hypnosis is often on relaxation, mental imagery, and suggestion rather than active control of physiological functions.
Correct Answer is D
Explanation
A. Report of perineal pain as 0 on a scale of 0 to 10: Perineal pain is more directly related to the effects of spinal anesthesia rather than fluid status. A decrease in perineal pain would be expected after the administration of spinal anesthesia, but it may not specifically indicate the effectiveness of the IV bolus.
B. Report of relief of pruritus: Pruritus (itching) is a common side effect of spinal anesthesia. Relief of pruritus can be expected after the administration of spinal anesthesia, but it is not a direct indicator of the effectiveness of the IV bolus.
C. Increased urinary output: Increased urinary output may indicate improved renal perfusion or fluid balance but is not a specific indicator of the effectiveness of the IV bolus in the context of spinal anesthesia for labor.
D. Blood pressure 110/70 mm Hg: This is the correct answer. Blood pressure is an important parameter to monitor, especially after administering an IV bolus of fluids. A blood pressure within the normal range (110/70 mm Hg) suggests that the bolus has been effective in addressing any hypovolemia or dehydration.
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