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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

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A rationale

Buttered whole wheat toast and coffee are not the best options for a patient with diarrhea. Whole wheat toast is high in fiber, which can exacerbate diarrhea. Coffee is a diuretic and can lead to further dehydration, which is a risk with diarrhea.

Choice B rationale

Granola is high in fiber and can worsen diarrhea. Strawberries, while a good source of vitamins, are also high in fiber. Tea can be dehydrating, which is not ideal when dealing with diarrhea.

Choice C rationale

Oatmeal is a bland and easily digestible food that can help to firm up the stool. Bananas are a good source of potassium and can help replace electrolytes that may be lost through diarrhea. Herbal tea is a non-caffeinated option that can help to soothe the digestive system.

Choice D rationale

Sausage is high in fat, which can worsen diarrhea. Eggs, while a good source of protein, can be hard to digest for some people and may not be the best choice during a bout of diarrhea. Milk is a common allergen and can cause digestive issues in people who are lactose intolerant.

A. Confirm that this value is helpful in reducing cardiac risk. B. Encourage the client to reduce consumption of fatty foods. C. Ask the client about hereditary cardiac risk factors. D. Explain that the client may need medication therapy.

Correct Answer is A

Explanation

Choice A rationale

High-density lipoprotein (HDL) cholesterol is known as the “good” cholesterol because it helps remove other forms of cholesterol from your bloodstream. Higher levels of HDL cholesterol are associated with a lower risk of heart disease. Therefore, an HDL level of 85 mg/dL (2.2 mmol/L) is helpful in reducing cardiac risk.

Choice B rationale

Encouraging the client to reduce consumption of fatty foods is not necessary in this case as the client’s HDL level is already high, which is beneficial for heart health.

Choice C rationale

Asking the client about hereditary cardiac risk factors is not the most relevant action in this case. The client’s HDL level is already high, which is beneficial for heart health.

Choice D rationale

Explaining that the client may need medication therapy is not necessary in this case as the client’s HDL level is already high, which is beneficial for heart health.

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Correct Answer is A

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