The nurse reviews the nurse’s notes and flow chart to identify trends.
Click to specify the notations that require immediate follow up (more than one notation may be correct.)
Exhibit 1: Patient’s Medical History
- Height: 5 ft 6 in (168 cm)
- Weight: 140 lb (63.5 kg)
- Delivery: The patient was transferred to the postpartum unit 1 hour after delivery of a 9 lb 1 oz (4.1 kg) female.
Exhibit 2: Nurse’s Notes and Flow Sheet
The patient was assisted to the bathroom where she voided 150 mL of clear yellow urine. Lochia rubra was moderate with small clots, no foul odor noted. The fundus was firm at the umbilicus. The episiotomy edges were well approximated, with no redness, edema, drainage, or ecchymosis. There was no pain, redness, or swelling in the calves.
- Boggy fundus 1 cm above the umbilicus
- Fundus rotated to the right
- Voided 200 mL of clear yellow urine
Exhibit 3: Vital Signs
- Heart rate: 96 beats/minute
- Blood pressure: 90/62 mm Hg
Exhibit 4: Provider’s Prescriptions
- IV infusing at 125 mL/hr
- A 1,000 mL bag of lactated Ringer’s solution containing 10 units of oxytocin is infusing.
Exhibit 5: Physical Examination Results
- Episiotomy: Intact with no redness
- Body System: Genital/Urinary and Circulatory
Boggy fundus 1 cm above the umbilicus
Fundus rotated to the right
Blood pressure: 90/62 mm Hg
Voided 200 mL of clear yellow urine
Heart rate: 96 beats/minute
IV infusing at 125 mL/hr
A 1,000 mL bag of lactated Ringer’s solution containing 10 units of oxytocin is infusing
Episiotomy: Intact with no redness
The Correct Answer is ["A","B","C"]
Based on the provided information, the following notations require immediate follow-up:
- Boggy fundus 1 cm above the umbilicus: A boggy (soft) fundus can indicate uterine atony, a condition in which the uterus fails to contract after delivery. This can lead to postpartum hemorrhage, a serious and potentially life-threatening condition.
- Fundus rotated to the right: A displaced fundus can be a sign of a distended bladder, which can interfere with uterine contraction and lead to postpartum hemorrhage.
- Blood pressure: 90/62 mm Hg: While this blood pressure isn’t extremely low, it is on the lower end of normal. Given the potential for postpartum hemorrhage indicated by the other findings, this should be monitored closely.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Increased BUN and serum creatinine are not typically symptoms of mononucleosis. These laboratory findings are more commonly associated with kidney dysfunction.
Choice B rationale
Ear pain and fever can be symptoms of many illnesses, including mononucleosis. However, they are not the most specific symptoms of this condition.
Choice C rationale
A positive Epstein-Barr virus test and malaise are common symptoms of mononucleosis. The Epstein-Barr virus is the most common cause of mononucleosis.
Choice D rationale
Elevated WBC and sedimentation rate can be seen in many inflammatory or infectious conditions, including mononucleosis. However, they are not the most specific symptoms of this condition.
Correct Answer is C
Explanation
Choice A rationale
While the supervisor of the neurology unit may have expertise in neurology, they are not typically responsible for coordinating the progression of a patient’s care following a spinal cord injury.
Choice B rationale
The nurse in charge of risk management is typically responsible for identifying and evaluating risks in the healthcare setting. They are not typically involved in the direct management of a patient’s care.
Choice C rationale
The nurse case manager is specifically trained to coordinate and manage the care of patients with complex conditions, including spinal cord injuries. They work with the patient, family, and healthcare team to develop a comprehensive care plan.
Choice D rationale
While an adult nurse practitioner can provide a high level of care, they are not typically responsible for managing the progression of a patient’s care following a spinal cord injury.
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