“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.”.

Answer and Explanation

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.

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Correct Answer is C

Explanation

The first action the nurse should take when caring for a client who has bladder distention following a vaginal birth is to assist the client to the bathroom. Bladder distention can occur after birth due to the pressure on the bladder during labour and birth.

Encouraging the client to empty her bladder will relieve the distention and promote comfort.

A. “Vaginal bleeding.”. B. “Fetal heart rate of 174 bpm.”. C. “Fundal height of 33 cm.”. D. “Abdomen soft on palpation and without tenderness.”.

Correct Answer is A

Explanation

Choice A rationale
Placenta previa is a condition where the placenta partially or completely covers the cervix. Vaginal bleeding, often without pain, is a key symptom and requires immediate medical attention.
Choice B rationale
While a fetal heart rate of 174 bpm is slightly above the normal range (110-160 bpm), it is not the most critical finding in a patient with complete placenta previa.
Choice C rationale
A fundal height of 33 cm at 32 weeks of gestation is within the expected range and does not require immediate follow-up.
Choice D rationale
An abdomen that is soft and non-tender is a normal finding and does not require immediate follow-up.

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“A nurse is assessing a patient who is 3 days postpartum. Which of the following findings should the nurse report to the provider?”

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has bladder distention following a vaginal birth. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

“A nurse is caring for a patient who is at 32 weeks of gestation and has complete placenta previa. Which of the following assessment findings requires immediate follow-up?”

Correct Answer is A

Explanation

A nurse is caring for a client who is at 33 weeks of gestation. The nurse is assessing the client 24 hours later. How should the nurse interpret the findings?

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A nurse is caring for a client who delivered by cesarean birth 6 hours ago. The nurse notes a steady trickle of vaginal bleeding that does not stop with fundal massage. Which action should the nurse take?

“A nurse is assessing a patient who is 3 days postpartum.

Which of the following findings should the nurse report to the provider?”