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.

Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Correct Answer: C. Measure the next voiding, then palpate the client's bladder.
Choice A rationale:
Catheterizing the client for residual urine volume is not necessary at this point because the woman has recently given birth, and frequent urination is common during the postpartum period. Additionally, catheterization poses risks of infection, so it should be reserved for situations where it is clinically indicated.
Choice B rationale:
Evaluating for normal involution and massaging the fundus is not relevant in this context. Fundal massage is performed after childbirth to ensure the uterus contracts and prevents excessive bleeding. The woman's concern is about frequent urination, which does not require fundal massage.
Choice C rationale:
Measuring the next voiding and palpating the client's bladder is the most appropriate action. The woman's increased frequency of urination could be due to postpartum diuresis, a normal physiological process where the body eliminates excess fluid accumulated during pregnancy. By measuring the next voiding and palpating the bladder, the nurse can assess for bladder distension or retention, which could be signs of a problem.
Choice D rationale:
Obtaining a specimen for urine culture and sensitivity is not indicated in this situation. There is no evidence to suggest that the woman has a urinary tract infection or other urinary issues that would warrant a urine culture at this time.
Correct Answer is C
Explanation
The correct answer is choicec. Ask the parents to explain what they understand about the child’s diagnosis.
Choice A rationale:
While it is important to support the parents’ decisions, this choice does not address the need for accurate information and understanding about the condition and its management.
Choice B rationale:
Hypospadias does not typically resolve on its own, and delaying surgery can lead to complications such as difficulty with urination and sexual function later in life.
Choice C rationale:
Asking the parents to explain what they understand about the child’s diagnosis ensures that they have accurate information and can make an informed decision about the timing of surgery.This approach also allows the nurse to correct any misconceptions and provide necessary education.
Choice D rationale:
Delaying surgery for hypospadias can lead to complications, including issues with urination and sexual function.It is important to address these potential risks with the parents.
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