A primiparous client was induced at 41-weeks gestation with misoprostol and oxytocin. She gave birth vaginally 4 days ago, and her prenatal course and delivery were uncomplicated. She was discharged home on day two with her newborn and has been breastfeeding around the clock. Discharge prescription included ferrous sulfate 325 mg PO twice daily. Client called her healthcare provider (HCP) this morning with fatigue, new onset of headache that was not relieved with ibuprofen, nausea, dizziness, weakness, and seeing “flashing lights.”. Client was instructed to come to the hospital for evaluation.
She may be experiencing postpartum preeclampsia.
She may have an infection that needs further evaluation.
Her symptoms could indicate anemia due to blood loss.
She may be experiencing normal postpartum fatigue.
The Correct Answer is A
Choice A rationale
Postpartum preeclampsia symptoms include headache, nausea, dizziness, weakness, and visual disturbances due to increased blood pressure. Normal BP is <120/80 mmHg. Labs may show elevated liver enzymes and proteinuria.
Choice B rationale
Infections postpartum can cause fever, localized pain, and discharge but are less likely to present with headache, nausea, dizziness, and visual disturbances. Normal WBC is 4,000-11,000 cells/mcL.
Choice C rationale
Anemia due to blood loss may cause fatigue, dizziness, and weakness but usually doesn't present with headache and visual disturbances. Normal hemoglobin is 12-16 g/dL for women.
Choice D rationale
Normal postpartum fatigue generally doesn't include severe headache, nausea, dizziness, and visual disturbances. It is mainly characterized by tiredness and mild discomfort as the body recovers.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Encouraging breastfeeding every 2 to 3 hours is contraindicated in HIV-positive mothers. Breastfeeding can transmit HIV to the infant despite maternal antiretroviral therapy, thus alternative feeding methods are recommended to prevent viral transmission.
Choice B rationale
Zidovudine administration within 6 to 12 hours after birth reduces the risk of perinatal HIV transmission. Early prophylaxis is crucial for preventing viral replication and reducing the likelihood of the infant acquiring HIV.
Choice C rationale
Administering antibiotics for 7 to 10 days is unnecessary unless there is evidence of bacterial infection. HIV-exposed infants need antiviral prophylaxis to prevent HIV transmission, not routine antibiotic treatment without specific indications.
Choice D rationale
Delaying the initial bath for 1 to 2 days is not recommended as it doesn't impact HIV transmission risk. Immediate skin cleansing can reduce exposure to maternal blood and bodily fluids, thus it’s standard practice to bathe newborns soon after birth.
Correct Answer is A
Explanation
Choice A rationale
The postpartum period is characterized by leukocytosis, where WBC counts can rise to 30,000/mm³ due to physiological stress. A WBC count of 15,000/mm³ is within the expected range for this client.
Choice B rationale
Perineal hematomas are more likely to cause localized pain and swelling than systemic symptoms. The assessment of perineal area is important but not the first priority in this context.
Choice C rationale
Monitoring temperature, heart rate, and respirations is crucial to identify infection but checking the differential to confirm normal physiological response to postpartum is prioritized first.
Choice D rationale
Notifying the HCP for an elevated WBC count without additional signs of infection is premature. A WBC count of 15,000/mm³ alone is not indicative of an infection in postpartum clients.
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