A nurse is assessing a client who is 1 hr postpartum. Which of the following findings should the nurse report to the provider?
Lochia rubra with small clots
Minimal perineal edema
Boggy fundus
Temperature 37.7° C (99.9° F)
The Correct Answer is C
. Lochia rubra with small clots:
Lochia rubra is the normal vaginal discharge occurring after childbirth, consisting of blood, mucus, and uterine tissue. It is expected for lochia to be present in the immediate postpartum period, and small clots are also considered normal as long as they are not excessive in size. Therefore, this finding is within the expected range for a client who is 1 hour postpartum and does not require immediate reporting to the provider.
B. Minimal perineal edema:
Perineal edema, or swelling in the perineal area, can be common after childbirth, particularly following vaginal delivery or if there was perineal trauma during labor. Some degree of perineal edema is generally expected in the immediate postpartum period and may resolve with time and appropriate care. As long as the edema is minimal and not causing significant discomfort or obstructing the assessment, it is not typically a cause for immediate concern or reporting to the provider.
C. Boggy fundus:
A boggy fundus refers to a uterus that feels soft and mushy instead of firm and well-contracted. It suggests uterine atony, which is a significant concern in the postpartum period as it can lead to excessive bleeding and postpartum hemorrhage. Therefore, a boggy fundus should be reported promptly to the provider so that interventions can be initiated to address the uterine atony and prevent complications.
D. Temperature 37.7°C (99.9°F):
A temperature of 37.7°C (99.9°F) is slightly elevated but may still fall within the normal range for the immediate postpartum period. While fever can indicate infection, a single temperature reading alone may not be sufficient to confirm an infection. It is important for the nurse to continue monitoring the client's temperature and assess for other signs and symptoms of infection before reporting to the provider. Therefore, this finding does not necessarily warrant immediate reporting unless accompanied by other concerning symptoms suggestive of infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Bilirubin 1 mg/dL (0.1 to 1 mg/dL):
Bilirubin levels can be elevated in conditions involving liver dysfunction or hemolysis, such as HELLP syndrome. However, a bilirubin level of 1 mg/dL falls within the normal range (0.1 to 1 mg/dL). While bilirubin levels may be elevated in some cases of HELLP syndrome, this particular value is not indicative of HELLP syndrome.
B. Uric acid 6.8 mg/dL (2 to 6.6 mg/dL):
Elevated uric acid levels are commonly seen in preeclampsia, but they are not specific to HELLP syndrome. Uric acid levels can rise due to decreased renal function and increased cell breakdown. However, while a level of 6.8 mg/dL is slightly elevated compared to the normal range (2 to 6.6 mg/dL), it alone does not confirm the presence of HELLP syndrome.
C. Fibrinogen 500 mg/dL (200 to 400 mg/dL):
Fibrinogen levels are typically increased in pregnancy, but they can be decreased in conditions associated with consumption coagulopathy, such as disseminated intravascular coagulation (DIC). However, elevated fibrinogen levels are not typically associated with HELLP syndrome. A level of 500 mg/dL is above the normal range (200 to 400 mg/dL), but this finding alone does not indicate HELLP syndrome.
D. Aspartate aminotransferase (AST) 80 units/L (4 to 20 units/L):
Aspartate aminotransferase (AST) is a liver enzyme that can be elevated in liver injury or dysfunction, which can occur in HELLP syndrome. An AST level of 80 units/L is significantly elevated compared to the normal range (4 to 20 units/L), suggesting liver dysfunction. Elevated liver enzymes are a characteristic feature of HELLP syndrome, making this finding the most indicative of HELLP syndrome among the options provided.
Correct Answer is ["D","E"]
Explanation
A. Abdominal distention:
Abdominal distention is not typically associated with hypoglycemia in newborns. It may be caused by other factors such as swallowed air during feeding or gastrointestinal issues.
B. Acrocyanosis:
Acrocyanosis, which is the blueness of the hands and feet, is a common finding in newborns and is not specific to hypoglycemia. It is often a result of the newborn's immature circulatory system.
C. Temperature instability:
Temperature instability, including hypothermia or hyperthermia, can occur in newborns for various reasons, but it is not specific to hypoglycemia.
D. Hypotonia:
Hypotonia, or decreased muscle tone, can be a sign of hypoglycemia in newborns. It may present as decreased activity, floppy movements, or poor feeding.
E.Jitteriness
Jitteriness, which is characterized by tremors or shaky movements, is a common manifestation of hypoglycemia in newborns. It is often observed when the newborn's blood glucose levels are low and can be a significant sign of hypoglycemia.
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