“A nurse is assessing a patient who is 3 days postpartum.
Which of the following findings should the nurse report to the provider?”
“Heart rate 89/min.”.
“Cool, clammy skin.”.
“BP 120/70 mm Hg.”.
“Moderate lochia serosa.”.
The Correct Answer is B
Choice A rationale
A heart rate of 89/min is within the normal range for an adult, and would not typically be a cause for concern.
Choice B rationale
Cool, clammy skin can be a sign of shock or other serious conditions such as hypoperfusion or inadequate blood flow, which could be a sign of hemorrhage or other circulatory issues. This is a significant finding that should be reported to the provider immediately. Hypoperfusion can lead to inadequate oxygen supply to the body’s organs and tissues, which can result in organ failure and other serious complications. Therefore, any signs of hypoperfusion, including cool, clammy skin, should be reported to the provider immediately for further evaluation and treatment.
Choice C rationale
A blood pressure of 120/70 mm Hg is within the normal range for an adult, and would not typically be a cause for concern.
Choice D rationale
Moderate lochia serosa is a normal finding in a woman who is 3 days postpartum. Lochia serosa is the term for the pink or brownish discharge that occurs after lochia rubra, the bright red discharge that occurs immediately after childbirth. Lochia serosa typically begins about 3- 4 days after delivery and can continue for up to 10 days postpartum.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Aspirin is generally not recommended for postpartum pain management due to its anticoagulant properties, which can increase the risk of bleeding. Furthermore, if the mother is breastfeeding, aspirin can pass into breast milk and potentially harm the baby.
Choice B rationale
Meperidine is a strong opioid medication that is typically reserved for severe pain. It is not usually the first choice for postpartum pain management due to its potential side effects and the risk of dependency.
Choice C rationale
Fentanyl citrate is a potent opioid that is typically used for severe pain and is often used in anesthesia. It is not usually used for routine postpartum pain management due to its potency and the risk of side effects and dependency.
Choice D rationale
Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that is commonly used for postpartum pain management. It is effective for relieving perineal pain and uterine cramping, and it is safe for use in breastfeeding mothers.
Correct Answer is D
Explanation
Choice A rationale
Storing a diaphragm in sterile water after each use is not necessary. After use, the diaphragm should be washed with mild soap and warm water, then air-dried.
Choice B rationale
Using an oil-based vaginal lubricant when inserting a diaphragm is not recommended. Oil- based lubricants can damage the material of the diaphragm, reducing its effectiveness.
Choice C rationale
Keeping the diaphragm in place for at least 4 hours after intercourse is correct, but it does not address the client’s postpartum status.
Choice D rationale
The client should have her provider refit her for a new diaphragm. After childbirth, a woman’s body undergoes changes that may affect the fit of her diaphragm. It is recommended that a woman be refitted for a diaphragm around 6 weeks postpartum, when the uterus and cervix have returned to normal size.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.