A nurse is assessing a client who is 3 days postpartum.
Which of the following findings should the nurse report to the provider?
Heart rate 89/min.
BP 120/70 mm Hg.
Moderate lochia serosa.
Cool, clammy skin.
The Correct Answer is D
Choice A rationale
A heart rate of 89/min is within the normal range for adults, and would not typically be a cause for concern.
Choice B rationale
A blood pressure of 120/70 mm Hg is considered normal for adults.
Choice C rationale
Moderate lochia serosa is a normal part of the postpartum period.
Choice D rationale
This is the correct answer. Cool, clammy skin can be a sign of postpartum hemorrhage, a serious condition that requires immediate medical attention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","F"]
Explanation
Choice A rationale: Swaddling the newborn with flexed extremities can provide a sense of security and help soothe the newborn. This is a common practice in managing neonates with Neonatal Abstinence Syndrome (NAS) as it can help reduce irritability and promote sleep.
Choice B rationale: Naloxone is not typically used in the treatment of NAS. Naloxone is an opioid antagonist and can precipitate withdrawal symptoms in opioid-dependent individuals. In a neonate with NAS due to maternal opioid use, naloxone can cause severe and immediate withdrawal.
Choice C rationale: Maintaining a low stimulation environment is crucial in managing neonates with NAS. These neonates are often hypersensitive to stimuli, and a quiet, dimly lit environment can help reduce irritability and promote sleep.
Choice D rationale: Breastfeeding is usually encouraged in mothers who are stable on their opioid replacement therapy, are not using illicit drugs, and have no other contraindications for breastfeeding. The benefits of breastfeeding include the passage of maternal antibodies and the promotion of mother-infant bonding.
Choice E rationale: The Ballard newborn screening is a tool used to estimate gestational age using physical and neuromuscular characteristics. It is typically performed shortly after birth and may not need to be performed each shift in a neonate with NAS.
Choice F rationale: Weighing the newborn daily is important in the management of NAS. Weight can provide information about feeding and hydration status, and any significant or sudden changes in weight can indicate a need for further evaluation.
Choice G rationale: Eye contact during feeding can promote bonding between the parent and the newborn. There is no need to avoid eye contact during feeding in a neonate with NAS.
Correct Answer is D
Explanation
The correct answer is choice d. The procedure is not necessary to determine the sex of the fetus.
Choice A rationale:
Chorionic villus sampling (CVS) is another prenatal test that can determine the sex of the fetus, but it is typically performed between 10-13 weeks of gestation. However, it is not the standard response to a request for amniocentesis.
Choice B rationale:
Age is not a criterion for performing an amniocentesis. This procedure can be done for various medical reasons regardless of the mother’s age.
Choice C rationale:
Scheduling an amniocentesis for the same day is not appropriate, especially since the primary purpose of amniocentesis is to diagnose genetic disorders, not to determine the sex of the fetus.
Choice D rationale:
This is the correct response because non-invasive methods like ultrasound can determine the sex of the fetus without the need for an invasive procedure like amniocentesis, which carries risks.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.