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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
A urinary output of 300 ml in 8 hours is within the normal range for a postpartum patient. The average urinary output is about 30 ml/hour.
Choice B rationale
Lochia rubra is a normal finding in the immediate postpartum period. It is the initial vaginal discharge after childbirth, which is red because it contains a large amount of blood. Changing perineal pads every 3 hours is considered normal.
Choice C rationale

A patient who is receiving magnesium sulfate and has absent deep tendon reflexes is experiencing magnesium toxicity. This is a serious condition that can lead to respiratory depression and cardiac arrest. The healthcare provider should be notified immediately.
Choice D rationale
Abdominal cramping during breastfeeding is a normal finding. During breastfeeding, the hormone oxytocin is released which can cause uterine contractions and lead to cramping.

A. Feed the newborn 5 to 10 min per breast. B. Expect two to four wet diapers every 24 hr. C. Allow the baby to feed at least every 3 hr. D. Offer the newborn 30 mL (1 oz) of water between feedings.

Correct Answer is C

Explanation

Choice A rationale
Feeding the newborn 5 to 10 minutes per breast may not be sufficient for the baby to get all the necessary nutrients. It is generally recommended to allow the baby to feed until they naturally let go of the breast.
Choice B rationale
Expecting two to four wet diapers every 24 hours is not accurate for a breastfeeding newborn. A well-fed newborn will typically have at least six wet diapers a day.
Choice C rationale
This is the correct answer. It is generally recommended to allow the baby to feed at least every 3 hours. This ensures that the baby gets enough nutrients and helps stimulate milk production.
Choice D rationale
Offering the newborn 30 mL (1 oz) of water between feedings is not recommended. Breast milk or formula should be the primary source of hydration for a newborn.

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

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

Exhibits