Which finding should the practical nurse (PN) instruct the postpartum client to report to the charge nurse?
Increased diaphoresis during the day and night.
Breast engorgement on the fourth postpartum day.
Lochia color that changes to light pink or white.
Sudden or persistent temperature above 100.5 F (38.0 C).
The Correct Answer is D
This is the finding that the PN should instruct the postpartum client to report to the charge nurse because it may indicate an infection, such as endometritis, mastitis, or urinary tract infection, that requires prompt treatment. The PN should also instruct the client to monitor for other signs of infection, such as foul-smelling lochia, redness or tenderness of the breasts, or dysuria.
A. Increased diaphoresis during the day and night is a normal finding in the postpartum period and does not need to be reported. It is caused by hormonal changes and fluid shifts that occur after delivery.
B. Breast engorgement on the fourth postpartum day is a normal finding in the postpartum period and does not need to be reported. It is caused by increased blood flow and milk production in the breasts.
C. Lochia color that changes to light pink or white is a normal finding in the postpartum period and does not need to be reported. It indicates that the uterine lining is healing and regenerating after delivery.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
This is the best site for the PN to observe because it allows for the detection of changes in color, such as pallor, cyanosis, or jaundice, that may not be visible on the skin surface. The sclera and mucous membranes are less pigmented than the skin and reflect the underlying blood flow and oxygenation.
A. Hands and feet are not the best site for the PN to observe because they may be affected by peripheral circulation, temperature, or edema, which can alter the color of the skin.
B. Forehead and face are not the best site for the PN to observe because they may have increased pigmentation or variations in tone that can mask changes in color.
C. Finger and toenails are not the best site for the PN to observe because they may be affected by nail polish, fungal infection, or trauma, which can alter the color of the nails.
Correct Answer is A
Explanation
Circumoral cyanosis is a bluish discoloration around the mouth that indicates inadequate oxygenation. It is an abnormal finding in a full-term newborn and requires immediate assessment and intervention by the PN.
The other options are not correct because:
B. A positive Babinski's reflex is a normal finding in newborns that indicates intact neurological function. It is elicited by stroking the sole of the foot and observing the fanning of the toes.
C. A negative Ortolani's sign is a normal finding in newborns that indicates no hip dislocation or dysplasia. It is elicited by abducting the hips and feeling for any clicking or clunking sensation.
D. A large sacral "stork bite" is a common benign birthmark that appears as a reddish patch on the lower back or nape of the neck. It usually fades within the first year of life and does not require any treatment.
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