The nurse is assessing a postpartum patient who had an uncomplicated vaginal delivery one hour ago. Which assessment finding requires immediate intervention?
Respiratory rate of 16 breaths/min
Pulse of 120 beats per minute
Temperature of 98.8 F (37.7 C)
Blood pressure of 120/88 mmHg
The Correct Answer is B
A. Respiratory rate of 16 breaths/min: Normal range, no intervention needed.
B. Pulse of 120 beats per minute: Correct. Tachycardia in the postpartum period can indicate hemorrhage or hypovolemia, requiring immediate assessment and intervention.
C. Temperature of 98.8°F (37.7°C): Normal postpartum temperature.
D. Blood pressure of 120/88 mmHg: Normal postpartum blood pressure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. She may have outbursts of anger: Possible but not the primary concern.
B. She may harm her infant: Correct. Postpartum depression can lead to severe thoughts of harming oneself or the baby, requiring immediate medical intervention.
C. She may lose interest in her husband: While possible, it is not the primary safety concern.
D. She may neglect her hygiene: This can occur but is not the most immediate concern compared to potential harm to the infant.
Correct Answer is D
Explanation
A. Acetaminophen is an appropriate analgesic for postpartum pain relief.
B. Encouraging oral fluids is essential for hydration, bowel function, and healing.
C. A sitz bath is beneficial for perineal healing, reducing pain and inflammation.
D. Correct. Enemas are contraindicated in clients with fourth-degree perineal lacerations because they may cause trauma, pain, and further damage to the perineal area. Stool softeners are preferred to prevent straining.
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