The nurse is reviewing the nurse’s notes and flow chart to identify trends.
Which notations require immediate follow-up?
Boggy fundus 1 cm above the umbilicus
Fundus rotated to the right
Voided 200 mL of clear yellow urine
Blood pressure 90/62 mm Hg
Correct Answer : A,B
Choice A rationale
A boggy fundus refers to an enlarged, soft, and tender uterus identified during physical examination. It is most commonly caused by uterine atony or adenomyosis. A boggy fundus 1 cm above the umbilicus requires immediate follow-up as it indicates that the uterus is not contracting properly after childbirth, which can lead to postpartum hemorrhage.
Choice B rationale
A fundus rotated to the right could indicate a distended bladder. This requires immediate follow-up as it can lead to urinary retention and other complications.
Choice C rationale
Voiding 200 mL of clear yellow urine is a normal finding and does not require immediate follow-up.
Choice D rationale
A blood pressure of 90/62 mm Hg is considered normal according to the American Heart Association. Therefore, it does not require immediate follow-up.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Instructing the patient that it is important to reduce the dose of the medication gradually is the best course of action. Temazepam is a benzodiazepine, and abrupt discontinuation can lead to withdrawal symptoms, which can be severe and include seizures. Therefore, it’s crucial to taper off the medication under the supervision of a healthcare provider.
Choice B rationale
Advising the patient to stop taking the medication immediately is not recommended due to the risk of withdrawal symptoms.
Choice C rationale
Encouraging the patient to obtain a prescription for a benzodiazepine antagonist is not typically the first line of action when discontinuing temazepam.
Choice D rationale
Discussing with the patient that there may be a need for additional sleep if the feeling of fatigue is present the next day is not directly addressing the issue. The patient’s feelings of being “hungover” are likely due to the effects of the medication, not a lack of sleep.
Correct Answer is A
Explanation
Choice A rationale
Osteoarthritis is a joint disease in which the tissues in the joint, including the cartilage, break down over time. The degradation of joint cartilage is the primary pathological condition that leads to the symptoms of osteoarthritis, such as increased pain and stiffness.
Choice B rationale
A systemic inflammatory response is not the primary cause of osteoarthritis. While inflammation can occur in the affected joint, osteoarthritis is not a systemic inflammatory disease like rheumatoid arthritis.
Choice C rationale
An infectious process in the synovial fluid is not typically associated with osteoarthritis. Infections can lead to a different type of arthritis known as septic arthritis.
Choice D rationale
A decrease in bone mineral density is associated with osteoporosis, not osteoarthritis. In osteoarthritis, the issue is primarily with the degradation of cartilage, not a loss of bone density.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.