“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 C
Explanation
Choice A rationale
A protective environment is not typically required for clients with MRSA141516. This type of precaution is usually used for clients who are severely immunocompromised and need to be protected from any potential sources of infection.
Choice B rationale
Droplet precautions are not typically used for clients with MRSA141516. These precautions are used for diseases that are spread through large respiratory droplets, such as influenza or pertussis.
Choice C rationale
Contact precautions are recommended for clients with MRSA141516. This involves using personal protective equipment and limiting patient movement outside of the room.
Choice D rationale
Airborne precautions are not typically used for clients with MRSA141516. These precautions are used for diseases that are spread through tiny airborne droplets, such as tuberculosis or chickenpox.
Correct Answer is B
Explanation
Choice A rationale
Dehydration could be a result of prolonged nausea and vomiting, but it is not the primary condition. Dehydration is a complication, not the cause of the symptoms.
Choice B rationale
The patient is most likely experiencing Hyperemesis Gravidarum, a severe form of nausea and vomiting in pregnancy. It’s more extreme than the typical morning sickness experienced during pregnancy and can lead to weight loss and dehydration. The nurse should ensure the patient stays hydrated and monitor their weight. Antiemetic medications may be prescribed to help control the vomiting.
Choice C rationale
Gastroenteritis typically involves both vomiting and diarrhea, often accompanied by abdominal pain and fever. The patient’s symptoms do not indicate gastroenteritis.
Choice D rationale
Food poisoning is usually associated with consuming contaminated food or water and often involves symptoms such as abdominal cramps and diarrhea, which the patient does not report.
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