The current vital signs for a primipara who delivered vaginally during the previous shift are: temperature 100.4° F (38° C), heart rate 58 beats/minute, respiratory rate 16 breaths/minute, and blood pressure 130/74 mm Hg. Which action should the nurse implement?
Report heart rate to healthcare provider.
Assess perineum for excessive lochia.
Document the vital signs in the record.
Administer a PRN dose of acetaminophen.
The Correct Answer is C
Choice A rationale
A heart rate of 58 beats/minute is within the normal range for adults, including those who have recently given birth. Therefore, there is no need to report this to the healthcare provider.
Choice B rationale
While assessing for excessive lochia is important in postpartum care, there is no indication from the given vital signs that this is necessary.
Choice C rationale
The vital signs provided are all within normal ranges for a postpartum patient. Therefore, the appropriate action would be to document these findings in the patient’s record.
Choice D rationale
There is no indication from the given vital signs that the patient has a fever or pain, so administering a PRN dose of acetaminophen is not necessary.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Purulent secretions are not typically associated with epiglottitis. Epiglottitis is an inflammation and swelling of the epiglottis and does not usually produce purulent secretions.
Choice B rationale
While a child with epiglottitis may appear anxious due to difficulty breathing, apprehension is not a specific symptom of epiglottitis.
Choice C rationale
A thick, muffled voice is a common symptom of epiglottitis. The inflammation and swelling of the epiglottis can affect the child’s voice, making it sound thick and muffled.
Choice D rationale
Wheezing is not typically a symptom of epiglottitis. While breathing difficulties are common in epiglottitis, they are usually due to the swelling of the epiglottis rather than constriction of the airways, which causes wheezing.
Correct Answer is B
Explanation
Choice A rationale
While assessing parenting skills is important in general, in this specific situation, the parent has expressed a fear of needles which is preventing them from being able to administer the insulin injections. Therefore, assessing parenting skills would not directly address the issue at hand.
Choice B rationale
If the child is capable and comfortable with administering their own insulin injections, this could be a viable solution to the problem. It is not uncommon for children, especially those who are older or more mature, to take over the administration of their own insulin injections. Choice C rationale
Encouraging the parent to handle the needles may be helpful, but if the parent has a strong fear of needles, this may not be a feasible solution. It’s important to respect the parent’s fear and find alternative solutions.
Choice D rationale
Asking if there is someone else who can help with the injections could potentially be a solution, but it would depend on the family’s situation and whether there is another person who is willing and able to help.
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