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Select all that apply. Which of the following findings require immediate follow-up?

Exhibits

Temperature

Pulse rate

Respiratory rate

Blood pressure

Lochia

Pain

Edema

Answer and Explanation

Correct Answer : A,B,D,E,G

Choice A rationale: The client’s temperature is 38.3°C (101°F), which is above the normal range (36.5-37.2°C or 97.7-99°F). This could indicate an infection, which is a common postpartum complication. Fever in the postpartum period can be due to endometritis, wound infection, mastitis, or urinary tract infection. Given the client’s report of a burning sensation during urination, a urinary tract infection could be a possibility. This finding requires immediate follow-up.

Choice B rationale: The client’s pulse rate is 110/min, which is above the normal range (60-100/min). This could indicate tachycardia, which can be a response to fever, pain, anxiety, or blood loss. Given the client’s elevated temperature and report of pain, this finding requires immediate follow-up.

Choice C rationale: The client’s respiratory rate is 22/min, which is within the normal range (12-20/min). While it’s slightly elevated, it’s not as concerning as the other findings. However, the nurse should continue to monitor the client’s respiratory rate along with other vital signs.

Choice D rationale: The client’s blood pressure is 140/90 mm Hg, which is higher than the normal range (90-120/60-80 mm Hg). This could indicate hypertension, which can be a complication in the postpartum period. Hypertension can lead to complications such as preeclampsia or eclampsia, which can be life-threatening. This finding requires immediate follow-up.

Choice E rationale: The client has a large amount of lochia rubra. Lochia rubra is normal for the first few days after delivery, but a large amount could indicate postpartum hemorrhage, especially if it’s accompanied by signs of hypovolemia such as tachycardia and hypotension. This finding requires immediate follow-up.

Choice F rationale: The client reports pain as 5 on a scale of 0 to 10. While pain is expected after a vaginal delivery, especially with an episiotomy, it should be manageable with analgesics. If the client’s pain is not well-controlled, it could indicate a complication such as infection or hematoma at the episiotomy site. However, given the information provided, this finding does not require immediate follow-up as much as the others.

Choice G rationale: The client has 3+ peripheral edema in bilateral lower extremities. While some edema is normal during pregnancy and the postpartum period, 3+ edema could indicate a complication such as deep vein thrombosis, especially if it’s accompanied by pain, warmth, or redness. This finding requires immediate follow-up.

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Correct Answer is C

Explanation

Choice A rationale
Raw carrots do not contain vitamin B12. Vitamin B12 is not naturally found in plant foods.
Choice B rationale
Fresh citrus fruits do not contain vitamin B12. Vitamin B12 is not naturally found in plant foods.
Choice C rationale
This is the correct answer. Fortified soy milk is a good source of vitamin B12 for vegans. Many brands of soy milk are fortified with vitamin B12 and other nutrients to help vegans meet their nutritional needs.
Choice D rationale
Brown rice does not contain vitamin B12. Vitamin B12 is not naturally found in plant foods.

A. “If you don’t hold the baby, it will make letting go much harder.”. B. “I’m sure you will be able to have another baby when you’re ready.”. C. “You can bathe and dress your baby if you’d like to.”. D. “You should name the baby so she can have an identity.”.

Correct Answer is C

Explanation

Choice A rationale
Telling a grieving mother that not holding her baby will make letting go much harder can be seen as insensitive and may not be true for all individuals. Each person’s grief process is unique.
Choice B rationale
Assuring the mother that she will be able to have another baby when she’s ready may be seen as dismissive of her current loss. It’s important to acknowledge the pain of losing this specific child, rather than focusing on future children.
Choice C rationale
This is the correct answer. Offering the mother the opportunity to bathe and dress her baby can provide a sense of closure and a chance to say goodbye. It allows the mother to care for her baby in the short time they have together.
Choice D rationale
While some parents may find comfort in naming their baby, it should not be presented as something the mother “should” do. The decision to name the baby is a personal one and should be left up to the parents.

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Select all that apply. Which of the following findings require immediate follow-up? Exhibits

Nursing Test Bank

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Select all that apply. Which of the following findings require immediate follow-up?

Exhibits