A nurse on the postpartum unit is caring for four patients.
For which of the following patients should the nurse notify the provider?
Patient who has a urinary output of 300 ml in 8 hours
Patient who reports lochia rubra requiring changing perineal pads every 3 hours
Patient who is receiving magnesium sulfate and has absent deep tendon reflexes
Patient who reports abdominal cramping during breastfeeding
The Correct Answer is C
Choice A rationale
A urinary output of 300 ml in 8 hours is within the normal range for a postpartum patient. The average urinary output is about 30 ml/hour.
Choice B rationale
Lochia rubra is a normal finding in the immediate postpartum period. It is the initial vaginal discharge after childbirth, which is red because it contains a large amount of blood. Changing perineal pads every 3 hours is considered normal.
Choice C rationale
A patient who is receiving magnesium sulfate and has absent deep tendon reflexes is experiencing magnesium toxicity. This is a serious condition that can lead to respiratory depression and cardiac arrest. The healthcare provider should be notified immediately.
Choice D rationale
Abdominal cramping during breastfeeding is a normal finding. During breastfeeding, the hormone oxytocin is released which can cause uterine contractions and lead to cramping.
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Related Questions
Correct Answer is C
Explanation
Choice A rationale
Moving the client onto their hands and knees is not the primary action taken during the McRoberts maneuver. The McRoberts maneuver involves an obstetrician or other healthcare provider flexing the patient’s thighs toward their abdomen.
Choice B rationale
Applying pressure to the client’s fundus is not the primary action taken during the McRoberts maneuver. The McRoberts maneuver involves an obstetrician or other healthcare provider flexing the patient’s thighs toward their abdomen.
Choice C rationale
This is the correct answer. The McRoberts maneuver involves an obstetrician or other healthcare provider flexing the patient’s thighs toward their abdomen. This maneuver helps to rotate the pelvis and open the sacrum to release the baby’s shoulder.
Choice D rationale
Pressing firmly on the client’s suprapubic area is not the primary action taken during the McRoberts maneuver. The McRoberts maneuver involves an obstetrician or other healthcare provider flexing the patient’s thighs toward their abdomen.
Correct Answer is B
Explanation
Choice A rationale
The influenza vaccine is recommended for all pregnant women, but it is not the only vaccine that should be administered to a pregnant woman who has received no immunizations during childhood.
Choice B rationale
The Tetanus, Diphtheria, Pertussis (Tdap) vaccine is recommended for all pregnant women, regardless of their prior immunization status. This vaccine protects against three serious diseases caused by bacteria. The antibodies that the pregnant woman’s body makes in response to the vaccine are passed on to the baby through the placenta, providing the baby with short-term protection against these diseases until they can receive their own vaccines.
Choice C rationale
The Hepatitis B vaccine is not typically given during pregnancy unless the woman is at risk for Hepatitis B infection.
Choice D rationale
The Pneumococcal vaccine is not typically given during pregnancy unless the woman has certain health conditions that increase her risk for pneumococcal disease
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