A nurse working on a postpartum unit is collecting data from four clients. Which of the following findings should the nurse report to the provider?

A client who has a reddened area on their right calf

A client who reports painful uterine contractions during breastfeeding

A client who has a urinary output of 125 mL in 4 hr

A client who reports changing their perineal pad every 2 hr

Answer and Explanation

The Correct Answer is C

A)   Incorrect- A reddened area on the calf might indicate a potential blood clot (deep vein thrombosis), which is important to assess but may not be the highest priority.
B)   Incorrect- Painful uterine contractions during breastfeeding can be a normal response due to oxytocin release during breastfeeding and might not require immediate reporting.
C)   Correct - A urinary output of 125 mL in 4 hours is significantly low and could indicate inadequate fluid intake, potential urinary retention, or other issues that need prompt attention. It is a sign of impaired renal function. This could indicate dehydration, blood loss, infection, or kidney injury. The nurse should assess the client's fluid intake and output, vital signs, urine specific gravity, and serum electrolyte levels. The nurse should also monitor the client for signs of hypovolemia, such as tachycardia, hypotension, and decreased skin turgor.
D)   Incorrect- Changing a perineal pad every 2 hours is within the normal range for postpartum bleeding and might not require immediate reporting.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is C

Explanation

Rationale:

A. Tachycardia is not a common or direct adverse effect of epidural anesthesia itself. While a rapid heart rate may occur secondary to maternal anxiety or as a compensatory response to hypotension, it is not the primary physiological marker for epidural complications. Heart rate typically remains stable or may decrease slightly as pain is relieved and sympathetic activity is modulated.

B. Fever is a documented potential adverse effect associated with epidural anesthesia, particularly during labor. The exact mechanism is multifactorial, potentially involving altered thermoregulation, reduced heat dissipation due to sympathetic blockade, or a non-infectious inflammatory response. Clinicians must distinguish this pharmacological pyrexia from maternal infection to ensure appropriate neonatal and maternal management following the delivery.

C. Tachypnea, or an increased respiratory rate, is generally not associated with epidural anesthesia. In fact, if the anesthesia level rises too high, it can lead to respiratory depression or a decreased rate due to the blockade of intercostal muscle nerves. Effective epidural analgesia usually promotes a more relaxed, normal breathing pattern by successfully alleviating the physiological stress and hyperventilation caused by acute pain.

D. Hypertension is the opposite of the expected vascular response to epidural anesthesia. The local anesthetic typically causes a sympathetic blockade, leading to peripheral vasodilation and a significant risk of maternal hypotension rather than high blood pressure. Monitoring blood pressure is a critical nursing priority because decreased systemic vascular resistance can compromise placental perfusion and lead to fetal heart rate decelerations.

A. Check urine for ketones. B. Administer glucagon C. Encourage an additional feeding. D. Recheck blood glucose in 4 hr.

Correct Answer is C

Explanation

A) Incorrect- Checking urine for ketones is not necessary if the newborn's blood glucose level is low but stable and the baby is asymptomatic.
B) Incorrect- Administering glucagon is not indicated for an asymptomatic newborn with a low but stable blood glucose level.
C) Correct - Encouraging additional feeding is appropriate for an asymptomatic newborn with a low blood glucose level. Regular feeding can help increase blood glucose levels.
D) Incorrect- Waiting 4 hours to recheck blood glucose might not be appropriate if the baby's blood glucose is currently low. Addressing the low blood glucose level is more immediate.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse working on a postpartum unit is collecting data from four clients. Which of the following findings should the nurse report to the provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who is receiving epidural anesthesia. Which of the following findings indicates an adverse effect of this method of pain management?

Correct Answer is C

Explanation

A nurse is caring for a newborn whose mother has gestational diabetes. The newborn has a blood glucose level of 30 mg/dL and is asymptomatic. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is reinforcing teaching with a client about how to minimize nausea in the first trimester of pregnancy. Which of the following instructions should the nurse give to the client?

A nurse is assisting in obtaining the fundal height measurement for a client who is at 32 weeks of gestation. Which of the following images indicates where the nurse should expect the client's fundus to be located?

A nurse is assisting with the care of a client who is in labor and has an epidural infusion for pain management. The client's blood pressure is 80/40 mm Hg. Which of the following actions should the nurse take?

A nurse is caring for a client who is in the early stages of labor and requests nonpharmacological interventions for pain. Which of the following actions should the nurse take?

A nurse is preparing to administer the hepatitis B vaccine to a newborn. Which of the following actions should the nurse take?

A nurse in an antepartum clinic is reinforcing teaching with a client who is pregnant and has a new prescription for oral ferrous sulfate. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is reinforcing teaching about laboratory testing with a client who is at 6 weeks of gestation. Which of the following statements should the nurse include?

A nurse is caring for a client who has hyperemesis gravidarum. The nurse should identify that the client is at risk for which of the following conditions?